For insurance companies seeking information about certifying dental plans to be sold on the MNsure marketplace. (To find information about qualified health plan (QHP) certification see the Minnesota Department of Commerce's website.)
Dental Plan Certification Guidance
Dental plans must meet specific federal requirements and market participation rules established under Minnesota state law before they can become qualified dental plans (QDPs) offered through MNsure. See the information below for guidance on certifying dental plans for sale on MNsure. You may also download the 2019 dental plan certification guidance as a PDF file.
The dental certification requirements and associated guidance are reviewed each year and updated when applicable. The purpose of this guidance is to describe the certification requirements intended to apply to dental plans to be sold on the Minnesota Health Insurance Exchange (“MNsure”) with effective dates beginning on or after January 1, 2019. MNsure refers to certified dental plans to be sold on MNsure as qualified dental plans (QDPs).
Certification guidance is also applicable to dental plans sold off MNsure, unless otherwise noted, if the dental plan is intended to satisfy pediatric dental requirements for health plans. Off-exchange QDPs must include essential health benefits (EHB) and must be MNsure-certified if they are to be used to fulfill the pediatric dental EHB requirement.
This guidance includes information about the applicable dental plan certification process, and also about the relevant timelines for issuers intending to offer QDPs for sale on MNsure with effective dates beginning on or after January 1, 2019.
The dental annual limitation on cost sharing (MOOP) for plan year 2019 will remain $350 for one child and $700 for two or more children.
Certified stand-alone dental plans (SADPs) are no longer required to comply with the actuarial value requirements of 70% (+/-2%, LOW) and 85% (+/-2%, HIGH). 45 C.F.R. §156.150, Application to stand-alone dental plans inside the Exchange.
Further clarifications to language used from previous guidance has been updated where appropriate.
Federal law requires that an issuer offering dental plans for sale on MNsure must have a certification issued by or recognized by MNsure, demonstrating that each dental plan it offers on MNsure is a QDP according to the applicable federal regulations. 45 C.F.R. §§ 156.200-156.295. Additionally, federal law requires that MNsure have in a place a process to ensure that QDP issuers meet various other requirements. 45. C.F.R. §§ 155.1020(c), and 155.1055. MNsure must also allow the offering of a limited scope dental benefits plan through MNsure if “the plan and issuer of such plan meets QDP certification standards, including §155.1020(c), except any certification requirement that cannot be met because the plan covers only” the pediatric dental essential health benefit.
In order to meet these federal requirements, MNsure relies on voluntary extension and application of existing provisions of state law to QDPs offered for sale on MNsure and, where applicable, to QDP issuers with respect to their portfolio of business with MNsure. By using this approach, MNsure will leverage the capacities of existing state regulatory agencies to carry out most components of the certification process, while directly carrying out only some components.
An issuer, with respect to its portfolio of business with MNsure, must be recognized by MNsure as demonstrating that each dental plan it offers on MNsure is QDP-certified. 45 C.F.R. § 156.200(a). MNsure will provide such notice to issuers.
QDP issuers must ensure that each QDP complies with benefit design standards, as defined in Sections 2707 and 1302 of the Patient Protection and Affordable Care Act. 45 C.F.R. §§ 156.20 & 156.200(b)(3). QDP issuers must also meet requirements for essential health benefits (1302(b)), Annual and Cost-sharing limits as described in section 1302 of the Affordable Care Act, and cover benefits included in the pediatric oral health benefit set in order to be MNsure-certified. The Minnesota Department of Commerce will assess compliance with benefit design standards for insurance companies through its form review process, while Minnesota Department of Health will assess compliance with benefit design standards for HMOs.
QDP issuers must be licensed and in good standing to offer dental insurance in each state in which it provides coverage. 45 C.F.R. § 156.200(b)(4). Minnesota Statutes, Chapter 62D.03 provides the applicable licensing certification standard for HMOs, while Minnesota Statutes, Chapters 60A.07 and 62C.08 provide the applicable licensing certification standards respectively for insurance companies and service plan corporations.
QDPs must offer a child-only plan and may choose to offer the opportunity to buy up to family coverage. At this time, MNsure will not facilitate the sale of adult-only QDPs on MNsure. MNsure will evaluate whether these offering requirements are met prior to permitting a QDP issuer to offer any approved QDP on MNsure and/or become MNsure-certified.
QDP issuers may not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation. 45 C.F.R. § 156.200(e). Minnesota Statutes 72A.20 and 62D.12 will also serve as the non-discrimination certification standard for QDPs.
QDP issuers offering certified dental plans for plan year 2019, and any limited scope pediatric dental plans, may only vary premiums in accordance with the rating factors and limitations used for varying QHP premiums. Minnesota Statute 62K.14.
Issuers offering certified dental plans for plan year 2019 must set rates for the entire benefit year, or for the SHOP plan year and issuers must annually submit required justification for rate increases in advance and post justifications on their websites. 45 C.F.R. § 156.210.
Other than the change to allow plan designs with a variety of actuarial values, certification requirements related to rating factors will remain unchanged for certified dental plans offered in plan year 2019 to ensure consumers have consistent and predictable premium cost information available as they shop for plans. Minnesota Department of Commerce will continue to review premium rate and actuarial information collected throughout plan year 2019 to monitor on and off-MNsure premium rates for relative consistency. Revised certification standards may include future certification requirements based on findings of the market participant’s practices.
QDP issuers offering dental plans off-MNsure have additional flexibility to adjust premiums based on other rating factors as long as it is in conformity with federal QDP certification guidance. The dental plan and benefits template will have a data field in which off-MNsure dental issuers will indicate whether they are committing to a guaranteed rate or an estimated rate, reserving the right to make further premium adjustments. Such flexibility must be actuarially justified, identified, and described in the actuarial memorandum.
For plan year 2019, SAPD issuers may offer the pediatric dental EHB at any AV level and are not required to enter the enter the “Issuer Actuarial Value“ within the plan and benefits template. Because there is no actuarial calculation in the template for SADPs, the AV for the pediatric dental benefit will need to be calculated by an actuary and listed on the AV supporting document.
MNsure must receive annual updates from issuers offering QDPs on MNsure regarding covered benefits and cost-sharing requirements of each QDP. 45 C.F.R. § 155.1020(c). QDP rates and benefits will be reviewed through existing established form and rate review processes established in state law by the Minnesota Departments of Commerce and Health.
A QDP issuer and its officials, employees, agents, and representatives, with respect to their portfolio of business with MNsure, must comply with applicable state laws regarding marketing and may not employ marketing practices that discourage enrollment of people with significant health needs. 45 C.F.R. § 156.225.
Minnesota Statutes 62Q.77, 62Q.79, and 72A.20 will serve as the certification criteria for marketing for QDPs. MNsure will use existing processes at the Minnesota Departments of Commerce and Health respectively to oversee compliance with these provisions.
Federal requirements §156.150, will serve as certification criteria for the Maximum Out-Of-Pocket (MOOP).
The dental annual limitation on cost sharing (MOOP) for plan year 2018 will remain $350 for one child and $700 for two are more children.
The per-child MOOP limit of $350 applies to each child individually. Once any enrolled child reaches $350 in out-of-pocket spending, the plan may not charge additional out-of-pocket costs for that child, regardless of whether the plan has one or more enrolled children.
The limit of $700 applies to plans with two or more enrolled children. A family may not be charged additional out-of-pocket costs once all enrolled children collectively have reached $700 in out-of-pocket costs.
The total cost sharing for EHB should not be greater than the MOOP.
Federal requirements 42 CFR 440.347 (10), will serve as certification criteria for the essential health benefits.
FAQ related to the prohibition on waiting periods for pediatric orthodontia (PDF), published on 5/26/2016 will serve as certification criteria for pediatric orthodontia.
Federal requirements 42 CFR 156.115 (6), will serve as certification criteria for age limits corresponding to pediatric services. All SADPs must cover pediatric dental benefits for individuals until at least the end of the month in which the enrollee turns 19 years of age.
All SADPs in the exchange must cover pediatric dental EHB.
QDP issuers with respect to their portfolio of business with MNsure, must ensure that QDP provider networks are sufficient in number and types of providers, including mental health and substance abuse providers, to assure that all services are accessible without unreasonable delay 45 C.F.R. § 156.230.
QDP issuers must also comply with a parallel requirement for network adequacy. QDP issuers will be required to ensure that dental service providers are available within 60 miles or 60 minutes transport time. The Minnesota Department of Health will perform network adequacy review for QDPs.
QDP issuers are required to make a provider directory for a QDP available to MNsure for publication online in accordance with guidelines from MNsure, and to potential enrollees in hard copy upon request. 45 C.F.R. § 156.230(b). A QDP issuer must publish an up-to-date, accurate, and complete provider directory, including information on the provider’s location, contact information and specialty, in a manner that is easily accessible to plan enrollees, prospective enrollees, and regulators. The electronic directory must be updated at least once a month pursuant to state law and federal regulations. 45 C.F.R. § 156.230(b); Minn. Stat. § 62K.075.
Consistent with guidance to issuers in the Federally Facilitated Exchange (FFE), issuers must include a minimum of 20 percent of designated essential community providers (ECPs) in the provider network service area. As with medical provider networks, stand-alone dental networks are subject to Minnesota Statutes 62Q.19, subd. 3 applying to ECPs. This means that if a dental ECP requests a contract, and meets the other contracting requirements, they must be offered participation in all networks of the health plan company. Networks for SADPs must include a minimum of 20% of dental ECPs available in the provider network service area. The minimum 20% threshold be calculated using Minnesota-designated dental ECPs located in the provider network service area as the basis (denominator) of calculation.. See the Minnesota Department of Health, Essential Community Providers page.
Carriers will find filing requirements for essential community providers as part of the filing requirements for network adequacy on the Minnesota Department of Health website.
QDP service areas must cover a minimum geographical area that is at least an entire county or group of counties unless MNsure determines that serving a smaller area is necessary, nondiscriminatory, and in the best interest of enrollees. A QDP service area must be established without regard to racial, ethnic, language, health status related factors, or other factors that exclude specific high utilizing, high cost, or medically underserved populations. 45 § C.F.R. 155.1055.
MNsure will generally require that a QDP service area is at least an entire county. MNsure will consider exceptions to the county service area requirement to the extent an issuer demonstrates the sub-county service area is necessary non-discriminatory, and in the best interests of enrollees. The Department of Health will review sub-county service areas (“Partial County Service Area Requirements") based on these criteria and all service areas to ensure they have been established without regard to racial, ethnic, language, health status related factors, or other factors that exclude specific high utilizing high cost, or medically underserved populations.
QDPs must be offered on a guaranteed availability basis, consistent with provisions of federal rules related to Health Insurance Market Rules (45 § C.F.R. 147.104, Guaranteed availability of coverage). Minnesota Department of Commerce will assess compliance with small employer participation and eligibility requirements per Minnesota Statutes 62L.03, Subd.3, for guaranteed issue of QDPs.
QDP issuers, with respect to their portfolio of business with MNsure, are also required to comply with:
45 C.F.R. §§ 156.150 (Application to stand-alone dental plans inside the Exchange)
156.220 (Transparency in coverage)
156.250 (Health plan applications and notice);
156.255 (Rating variations)
156.260 (Enrollment periods for qualified individuals)
156.265 (Enrollment process for qualified individuals)
156.270 (Termination of coverage for qualified individuals)
156.285 (Additional standards specific to SHOP); and
156.290 (Non-renewal and decertification)
156.1250 (Acceptance of certain third party payments).
The presence of QDPs on MNsure offers flexibility to issuers of QHPs to determine whether or not to include pediatric oral health services as a bundled part of their benefit sets encompassing all aspects of EHB, including pediatric dental. A QDP could potentially be offered through a separate stand-alone dental plan that could be purchased along with any QHP offered in a particular service area, or through an endorsed plan attached to a specific QHP offered on MNsure. At this time MNsure information technology infrastructure does not allow the sale of endorsed limited scope dental plans attached to a specific QHP to be offered on MNsure.
Filing of potential QDPs must occur by the filing timeframe as established jointly by Minnesota Department of Commerce, Minnesota Department of Health, and MNsure, in order to facilitate the certification process being completed in time for the QDP to be offered during the next plan year open enrollment period. QDPs can be filed at any time, but a filing made after the established filing deadline will not have priority treatment for the next plan year open enrollment period. QHPs and QDPs to be offered on MNsure during the next plan year open enrollment period must be certified prior to the beginning of the open enrollment period.
Special note: New template plan management filing instructions and requirements have been added for 2019. Please see the “Letter to Carriers” and “2019 Annual Instruction Guide” for more details.
