Dental Plan Certification

The dental certification requirements and associated guidance are updated each year. 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, 2018, and to QDP issuers with respect to their portfolio of business with MNsure for effective dates beginning on or after January 1, 2018. 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 that must include the essential health benefits (EHB) and therefore need to be MNsure-certified. A dental plan must be MNsure-certified if it is to be used to satisfy 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, 2018.

• In line with federal requirements, the requirement for Quality Information System and Quality Rating System data have been removed for plan year 2018.
• New federal requirements §156.150, regarding maximum out-of-pocket (MOOP), has been added to Section 3. 
• Federal requirements 42 CFR §156.115 (6), regarding the criteria for age limits, has been added to Section 3. 
• Federal requirements related to the prohibition on waiting periods for pediatric orthodontia has been added to Section 3. 
• Per 45 C.F.R. § 156.230(b) and Minn. Stat. § 62K.075., under section 4 guidance has been added regarding the requirement for electronic directories to be updated at least once a month
• Further clarifications to language used from previous guidance has been updated where appropriate.

Federal law requires that a health insurance issuer offering health plans for sale on MNsure must have a certification issued by or recognized by MNsure, demonstrating that each health 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 QHP 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 QHP 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./p>

1. An issuer, with respect to its portfolio of business with MNsure, must be recognized by MNsure as demonstrating that each health plan it offers on MNsure is a QHP. 45 C.F.R. § 156.200(a). MNsure will provide such notice to issuers. QDP issuers must also meet a parallel requirement that each dental plan it offers on MNsure is a QDP.
2. QHP issuers must ensure that each QHP 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 a parallel requirement 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.
3. QHP issuers must be licensed and in good standing to offer health insurance in each state in which it provides coverage. 45 C.F.R. § 156.200(b)(4). QDP issuers must also meet a parallel requirement to be licensed and in good standing. 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.
4. Each QHP issuer must offer at least one QHP in silver coverage level and at least one QHP in the gold coverage level and a child-only plan throughout each service area in which it offers coverage through MNsure. 45 C.F.R. § 156.200(c)(1-2). QDP issuers will also need to meet parallel offering requirements. Actuarial value levels are, however, measured and described differently for QDPs under federal regulations and thus offering requirements for QDPs are structured consistent with federally defined actuarial value levels. Each QDP issuer offering QDPs for sale that are intended to satisfy the pediatric dental EHB requirement, must offer at least one QDP at the low actuarial value level and at least one QDP in the high actuarial value level. 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.
5. QHP 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). QDP issuers must also meet a parallel requirement of non-discrimination. Minnesota Statutes 72A.20 and 62D.12 will serve as the non-discrimination certification standard for QDPs.

QDP issuers offering certified dental plans for plan year 2018, 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 2018 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.

Certification requirements related to rating factors will remain unchanged for certified dental plans offered in plan year 2018 to ensure consumers have consistent and predictable premium cost information available as they shop for plans. Minnesota Department of Commerce will review premium rate information collected throughout plan year 2018 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.

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.

1. QHP 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. QDP issuers must also meet a parallel requirement related to marketing and benefit design.
2. 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.
3. 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.
4. Federal requirements 42 CFR 440.347 (10), will serve as certification criteria for the essential health benefits.
5. 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.
6. Federal requirements 42 CFR 156.115 (6), will serve as certification criteria for age limits corresponding to pediatric services.

Network Adequacy 

QHP issuers with respect to their portfolio of business with MNsure, must ensure that QHP 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. 

Carriers will find filing requirements for network adequacy on the Minnesota Department of Health website. 

Provider Directories

QHP issuers are required to make a provider directory for a QHP 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 QHP issuer, including issuers of SADPs, must publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations, 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 ECP’s. 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 percent of dental ECPs available in the provider network service area. The minimum 20 percent 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.

QHP 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 QHP 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.

QDPs will need to meet a parallel requirement for service areas. 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 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 of QHPs); 
• 156.1250 (Acceptance of certain third party payments).

The presence of QDPs on an 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.