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Plan Management Toolkit

Please note that this page will be updated regularly.  If you would like to receive email notifications when an update is released, please add your email address in the registration box below.  To easily identify the new information, the date the question/answer was added or edited is noted after the end of each response.  The email notifications will also include which questions are new. 

The Department is also welcoming plan management questions.  We will not be responding to submitted questions, one by one, but rather placing the question and answer on this page so all stakeholders will be able to see the information. Please send appropriate questions to planmanagementquestions@insurance.ohio.gov. 


The Department will be hosting trainings regarding form, rate and binder filings via webinar on Wednesday, March 25th from 1:00 - 2:30 and Tuesday, April 7th from 1:00 - 2:30.

More information and participation instructions will be sent closer to the date of the webinar - for now, please mark your calendars.


Rating Questions
  1. What are the applicable rating areas for Ohio?
    • Ohio has 17 approved rating areas for the individual and small group markets.  Click here for a map of the approved areas. updated 2/13/14
  2. Which rating factors will apply to: a) employers with employees residing across the state or out-of-state; and b) students that are out of state and covered under their parents’ plan?
    • In determining which rating factors an insurer must apply to employers with employees residing across the state or out-of-state and employee dependents living out-of-state, the insurer must apply the rating factors applicable to the employers’ principal place of business. updated 2/13/14
  3. What are the applicable timelines for rate filings for products being sold on the exchange?
    • In order for ODI to transfer approved products to the Exchange, insurers need to submit rate filings for QHP/exchange products before May 23, 2014.  Please note we encourage insurers to file rates for QHPs that will also be sold off exchange at this time. updated 2/13/14

  4. Regarding the Rate Filing Guidance Checklist, is there a separate version for Large Group filings? 
    • This checklist has been updated to address applicability for Large Group filings.  Pages 4-8 do not apply to Large Group filings. updated 2/26/14
  5. Per Federal communications the URR Module of HIOS is now capable of handling quarterly index rate submissions for Small Group market single risk pools. Will ODI accept filings for 3rd and 4th quarter rate updates and has ODI set timelines for these rate filings?

    • Yes, ODI will accept 3rd and 4th quarter rate updates for on and off exchange small group plans. 
    • For on exchange plans:
      • 3rd quarter 2014 small group quarterly index rate filings should be submitted via SERFF before April 8, 2014.
      • 4th quarter 2014 small group quarterly index rate filings should be submitted via SERFF before May 23, 2014. The Department cannot accept 4th quarter rate filings after 2015 rate review has begun.
      • When review of the submission is complete, companies will need to submit updated binder templates via SERFF for the on exchange rates. ODI expects to release additional timelines for template submissions once CMS finalizes the federal timeframes.
    • For off exchange plans:
      • 3rd quarter 2014 small group quarterly index rate filings should be submitted via SERFF before April 8, 2014.
      • 4th quarter 2014 small group quarterly index rate filings should be submitted via SERFF before July 21, 2014updated 3/7/14
  6. 9/12/14 is the deadline for large group rate filings for 1/1 rates. Is there any limitation on 2/1/15 rates or later?
    • ODI has not released deadlines beyond those we have already announced.  updated 3/25/14
  7. Are carriers required to submit a Rate Data Template for off exchange small group and off exchange individual rate filings?
    • Upon further consideration, carriers are not required to submit a Rate Data Template for off exchange small group and off exchange individual rate filings.  This is a change from information provided during training on 3/13/14 and 4/7/14.  Please note that the Rate Data Template is still required for on exchange binder filings. updated 6/26/14   

  8. Will the Department issue guidance to carriers regarding its expectations for compliance with the CMS Final Rule on Composite Rating for the small group market beginning January 1, 2015?

    • Our understanding is that the federal rules require all companies to follow the federally mandated composite rating rules for small employer plans in 2015, if the carrier chooses to use composite rating.  Please note these rules are new for 2015 plans and apply both on and off the exchange.  ODI is soliciting comments from carriers to determine whether an Ohio specific composite methodology is appropriate and if so, propose such a methodology for use in 2016.  Please email planmangagmentquestions@insurance.ohio.gov with comments on this issue. updated 9/4/14



    Filing Process Questions
  1. What are the applicable timelines for form filings for products being sold on the exchange?
    • In order for ODI to transfer approved products to the Exchange, insurers need to submit form filings for QHP/exchange products before April 14, 2014.  Please note we encourage insurers to file forms for QHPs that will also be sold off exchange at this time. updated 2/13/14
  2. Can a non-grandfathered individual or small group filing, being sold off the exchange, be submitted after April 14, 2014?
    • Yes, in order for companies to have approval in time for open enrollment, forms and rates for non-grandfathered individual and small group products being sold off the exchange should be submitted before August 1, 2014. Please note we encourage insurers to follow on exchange timelines for QHPs that will also be sold off exchange. updated 2/13/14  
  3. What are the applicable timelines for form and rate filings for products being sold to large groups?
    • In order for ODI to approve large group products for use by January 1, 2015, insurers should submit form and rate filings before September 12, 2014updated 2/13/14
  4. Will insurers be permitted to use matrix filings 
    • No, ODI will continue to prohibit matrix filings for the individual or small group market.  Due to the level of validation that is required to review forms under the new market rules, matrix filings are no longer a feasible option.  However, at this time, ODI will continue to allow matrix filings on grandfather products and large group products. updated 2/13/14
  5. Will ODI continue to allow separate rate review and product review for major medical filings? 
    • Yes, as we did last year, we will continue to utilize separate form and rate filing and review for major medical filings. updated 2/13/14 
  6. Do policy forms need to be refiled if the forms are staying the same?
    • No, if nothing in the form is changing, forms do not need to be refiled.  However, corresponding rates do need to be filed to be current for the 2015 plan year.  More specific information can be found in appendix E of the filing guidance document, here. updated 3/25/14 
  7. Does ODI expect a redline copy of the EOC/policy when companies file revisions to a previously approved form?
    • When filing revisions to a previously approved form, please include a redlined copy of the revised form under the Supporting Documentation SERFF tab.  For additional information on filing forms, please see the ACA Compliant Form Filing Guidance which can be obtained hereupdated 3/25/14 

  8. Are the Microsoft Excel EHB and RX Data Worksheets required to be converted into PDF form for filing purposes?
    • Please submit the EHB and RX Data Worksheets in the excel format. updated 6/26/14

    Dental Questions
  9. What are the applicable timelines for submitting forms and rates for Stand-Alone Dental Plans (SADPs) and off-Exchange certified dental plans?  
    • Both SADPs and exchange certified dental plans sold off the exchange should follow the applicable deadlines for forms and rate for products sold on the exchange – April 14, 2014 for forms and May 23, 2014 for rates. updated 2/13/14
  10. When is the deadline for submitting QHP Binders for SADPs and off-Exchange certified dental plans?    
    • QHP Binders that include a SADP must be submitted with the Department no later than June 30, 2014.  Please note that this includes SADPs that seek Exchange certification, but will be sold solely off of the Exchange. updated 2/13/14

  11. If a Stand Alone Dental Plan (SADP) is applying for certification for off-exchange, which deadline applies? 
    • All SADPs applying for exchange certification, regardless of whether the plan intends to be sold on or off the exchange, should follow the April 14th deadline for forms and the May 23rd deadline for rates.  For SADPs that are being sold off the exchange and are not applying for exchange certification should follow the August 1st deadline for rates and forms. updated 2/26/14

  12. Are binders required for SADP certification this year?  
    • Yes, all SADPs applying for exchange certification, regardless of whether the plan is intended to be sold on or off the exchange, are required to submit binders.  These binders are considered the QHP application.  SADPs applying for exchange certification should also follow the June 30th binder submission deadline. updated 2/26/14
  13. For carriers not offering Embedded Pediatric Dental, what are ODI’s requirements for “reasonable assurance” of coverage?
    • A health plan issuer that provides coverage without pediatric dental benefits must ensure that it is reasonably assured that the applicant has obtained or will obtain pediatric dental coverage through a certified pediatric dental plan. It is the issuer’s responsibility to ensure it is in compliance with federal law. updated 6/26/14 


    Qualified Health Plan Questions
  14. What are the applicable timelines for the Qualified Health Plan (QHP) applications?
    • QHP applications will continue to be submitted in SERFF using the “Binder” filing functionality.  In order for ODI to transfer approved products to the Exchange, insurers need to submit Binders filings for QHP/exchange products before June 30, 2014. updated 2/13/14
  15. Must insurers complete all required templates and attestations before submitting its Binder to ODI?
    • No, ODI strongly encourages insurers to submit binder filings well in advance of the June 30, 2014 deadline.  ODI staff can complete reviews on attestations and other required templates while form and rate review is ongoing.  However, ODI will not review the Plans and Benefits template or the Rate Data template until the review on the applicable form and/or rate filing is complete. updated 2/13/14 
  16. Do plan binders need to be submitted annually?  
    • Yes, the SERFF binder contains the insurer’s QHP application.  The federal rules require all plans (including stand-alone and embedded dental plans) to submit QHP applications annually, regardless of whether the plan was previously sold on the exchange.  See also, 2015 Letter to Issuers, page 7.
      updated 3/25/14 

  17. When do the templates need to be submitted?
    • In order to submit a template, the templates themselves must be finalized by CMS and the ability to submit the templates for Plan Year 2015 and the Binder submission functionality must be available within SERFF.  To date these items are not complete and we have not received specific information on availability.  At this time we expect both items to be available by mid-May.  ODI has announced that the application binders, which include the templates, must be submitted in SERFF by June 30, 2014. 

      Please keep in mind that templates must reflect the final approved forms.  Accordingly, ODI will not begin reviewing template submissions until the Form review for a product has been completed.
      updated 3/25/14 
  18. Do policy forms need to be associated with the plan binders if there are no changes from the previous year’s filing?
    • Yes, insurers will need to associate the appropriate forms and rates with the 2015 binder.
      updated 3/25/14 

  19. Can you confirm the accreditation standard for year 2 QHP issuers will be satisfied by a commercial or Medicaid health plan accreditation for the same state in which the issuer is offering a Marketplace plan?
    • In the 2015 Letter to Issuers, Chapter 2, Section 5, CMS further provides that “QHP issuers will be required to attest that the administrative policies and procedures applicable to the Marketplace products have been reviewed and approved by a recognized accrediting in organization in compliance with 45 C.F.R. 155.1045 (b)(2).” updated 3/25/14
  20. Has CMS recently released additional guidance to clarify non-discriminatory standards in benefit design? 
    • CMS provided guidance on benefit design compliance with non-discrimination standards in its 2015 Letter to Issuers, located at http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2015-final-issuer-letter-3-14-2014.pdf.  CMS also addressed the impermissibility of imposing waiting periods on essential health benefits (except on pediatric orthodontia) in an FAQ released on May 16, 2014.  
      In the QHP Master Review Tools for 2015, CMS provides examples of potentially discriminatory benefit designs, explains why each example is potentially discriminatory, and suggests ways to minimize the potential for discrimination for each example provided.  The examples cover a wide range of design features including exclusions, cost sharing, the definition of medically necessity, drug formularies, visit limits, benefit substitution, and utilization management.  The 2015 QHP Application Review Tools can be found in the Issuer Community section of zONE, https://zONE.cms.gov/.  For your convenience, a copy is attached. updated 6/26/14
      2015 Non-Discriminatory Benefit Design QHP Standards   


     Essential Health Benefits
  21. What are the applicable Essential Health Benefit (EHB) requirements for the 2015 benefits?
    • EHBs for 2015 are the same as 2014.  Please click here for EHB resources. updated 2/13/14
  22. Where is the most current information on Ohio’s Essential Health Benefits (EHBs)?
    • Issuers should use the Ohio Essential Health Benefits Resource Document for the 2015 Plan Year published by ODI here. Please note that the Ohio EHB details published on the CMS’ website (http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html#Ohio) may not be accurate and should not be used as a resource. updated 3/25/14
  23. Does ODI allow actuarial equivalent substitutions within a benefit category? If so, what is the process/what documentation is required? 
    • Actuarially equivalent substitutions within a benefit category may be submitted for approval.  Please include the required supplemental information described in the EHB Data Worksheet when filing your rate submission. updated 3/25/14
  24. Will applying a 30 visit per year limit on mental health outpatient services as defined in the Governor’s December 26, 2012 letter comply with federal mental health parity?
    • It depends on the visit limits, if any, that apply to outpatient medical/surgical benefits provided under the plan.  Plans subject to federal mental health parity must provide mental health and substance use disorder benefits in parity with medical/surgical benefits within the same classification or sub classification. Therefore, to the extent that a plan’s applicable limits for outpatient medical/surgical benefits exceed 30, limits for outpatient mental health benefits must be provided in parity.  If a plan’s applicable limits for outpatient medical/surgical benefits are less than 30, then coverage should be provided as defined in the Governor’s letter. updated 6/26/14

  25. Can new companies, or companies adding a new line of authority, file products for review concurrently with their application for a Certificate of Authority (COA)?  
    • Yes, in order to accommodate federally required timelines, both new companies and companies adding a line of authority may file a product simultaneously with the COA application.  If your company plans to take advantage of this option, please notify your assigned risk assessment analyst. updated 2/13/14 

  26. Will ODI keep form and/or rate filings confidential until after they are approved?
    • Filings will become public in accordance with current Ohio statutory requirements. updated 2/13/14
  27. What is the definition of the small group market in Ohio?   
    • The small group market in Ohio for coverage provided on or after January 1, 2014, is 1 to 50 employees.  Federal law requires sole proprietors purchase insurance through the individual market.  However, as long as there is an employer employing a non-spouse employee, that employer can purchase coverage in the small group market – even if there is only one covered individual. updated 3/7/14

  28. Question #20 states the definition of small employer is 1-50. Was there an amendment made to Ohio Revised Code 3924.01 to change the definition of small group?
    • No, federal law defines the small group market as 1 to 100 but allows states to elect to keep the upper threshold at 50 until 2016, which Ohio elected to do. Therefore, in accordance with federal law, Ohio’s definition of small group is 1 to 50 until 2016. updated 2/26/14

  29. Is there a due date for fourth quarter data for Form INS7226, the HIC quarterly exhibit of open panel premium, enrollment and utilization for Q4 2013 data? 
    • The due date is March 1, 2014 for the referenced Q4 2013 data submitted with Form INS7226. 
      updated 2/26/14

  30. Will Ohio be allowing the extended transitional relief for plans that do not meet certain ACA requirements through 2016?
    • On March 5, 2014, CMS announced that insurers would be permitted to continue offering plans that are not fully ACA compliant through policy years beginning on or before October 1, 2016, at the state’s option. Ohio issued Bulletin 2014-01 addressing the requirements for insurers who wish to renew non-ACA compliant individual and small group coverage in light of CMS’ transitional policy. updated 6/13/14
  31. Will Ohio be choosing to allow employee choice/premium aggregation in the SHOP for 2015? 
    • Ohio did not submit a recommendation to HHS requesting a one-year transition policy for employee choice. Therefore, pursuant to federal regulations, for plan years beginning on or after January 1, 2015, FF-SHOPs must provide qualified employers with a choice of two methods to make QHPs available to qualified employees: they can offer employees a choice of all QHPs at a single level of coverage, or they can offer a single QHP. In addition, related to premium aggregation, the SHOP in Ohio is required to send each participating employer a single monthly bill for plan years beginning on or after January 1, 2015.  updated 6/13/14
  32. Federal law requires plans to extend coverage to dependents to age 26.  Are we also required to comply with ORC Section 3923.24 (dependent coverage to age 28)?
    • Yes, in Ohio, certain eligible children may continue under their parents’ coverage until they turn 28.   For additional information, please click hereupdated 3/25/14
  33. On March 14, 2014, CMS issued an informational bulletin that included draft standard notices required when discontinuing or renewing a product in the group or individual market and gives states the option of developing state required notices in lieu of the federal notices.  Will Ohio be developing different notices?   
    • The Department has reviewed the federal notices, which appear to comply with Ohio law.  Therefore, the Department will not be issuing a state specific notice. updated 6/26/14  
  34. How will the Department of Insurance evaluate product withdrawal and uniform modifications for purposes of the federal requirements?
    • The Department will review plan filings to ensure compliance with uniform modification and product withdrawal standards.  This information will be requested via rate filings. Issuers must comply with standards related to uniform modifications and product withdrawal. Issuers will need to demonstrate compliance with uniform modification standards by providing justification describing compliance with the final rule.  For requirements related to service area and cost-sharing structure, the Department intends to apply these standards broadly and will accept reasonable interpretations. Issuers must also ensure that any modifications comply with all applicable prohibitions on discriminatory benefit designs.
      updated 6/26/14


    This information is provided as general guidance and is subject to change.  Though reasonable efforts have been taken in compiling this information, the Department does not warrant the completeness or accuracy of the information, nor accept responsibility for errors, omissions or advice given or for any losses arising directly or indirectly from reliance upon information contained in this publication.

The State of Ohio is an Equal Opportunity Employer

Ohio Department of Insurance
50 W. Town Street, Third Floor - Suite 300
Columbus, Ohio  43215
John Kasich, Governor | Jillian Froment, Director
General Info: 614-644-2658 | Consumer Hotline: 800-686-1526
Fraud Hotline: 800-686-1527 | OSHIIP Hotline: 800-686-1578