COHBE Qualified Plan Certification 1

SB-200 Requirements CRS The exchange shall not duplicate or replace the duties of the commissioner established in section , including rate approval, except as directed by the federal act. The exchange shall foster a competitive marketplace for insurance and shall not solicit bids or engage in the active purchasing of insurance. CRS (1) – (i) Consider the unique needs of rural Coloradans as they pertain to access, affordability, and choice in purchasing health insurance; – (j) Consider the affordability and cost in the context of quality care and increased access to purchasing health insurance; and – (k) Investigate requirements, develop options, and determine waivers, if appropriate, to ensure that the best interests of Coloradans are protected. 2

Marketplace Rules 3

Plan Management Certification, recertification, decertification – Regulatory requirements – Accreditation standards Business Relationship – Data exchange standards – Customer service standards Exchange will develop objective plan management standards and communicate those standards to carriers before certification. 4

Exchange Partners Exchange will work with Division of Insurance, Department of Public Health and Environment, and Department of Health Care Policy and Financing to minimize QHP burdens 5

Certification Requirement Activities AccreditationLicensure Requirements Complaint DataMarketing Requirements Claim Payment DisclosuresMLR requirements Discriminatory Benefit Design ReviewNetwork Adequacy Essential Benefit ValidationOut-of-Network Disclosure Requirements Essential Community Health ProvidersQHP Quality Measures Financial DisclosuresProvider Directory Formulary RequirementsSolvency Requirement 6 AccreditationMarketing Requirements Complaint DataMLR requirements Claim Payment DisclosuresNetwork Adequacy Discriminatory Benefit Design ReviewOut-of-Network Disclosure Requirements Essential Benefit ValidationPlan Differentiation Essential Community Health ProvidersProvider Directory Financial DisclosuresQHP Quality Measures Formulary RequirementsRate Review Licensure RequirementsSolvency Requirement

State, Federal, or UX Guidance Accreditation (Fed)MLR Requirements (Fed) Complaint Data (State)Network Adequacy (State) Claim Payment Disclosures (State)Out-of-Network Disclosure Requirements (State) Financial Disclosures (State)Provider Directory (UX) Formulary Requirements (UX)Rate Review (State) Licensure Requirements (State)Solvency Requirement (State) 7

New Processes Some Existing Processes Essential Community ProvidersQHP Quality Measures Marketing Requirements Completely New Processes Discriminatory Benefit DesignEssential Benefit Validation Plan Differentiation 8

Decertification The Exchange will only decertify an issuer during the year if the issuer is not able to meet responsibilities (loses licensure, insolvency, or inadequate network, etc.) – The Exchange will work to move members to a new QHP in an efficient manner An issuer who fails to meet necessary business partnership levels will not be recertified but members will continue to be enrolled in the QHP 9

Recertification The Exchange will develop an annual recertification process The recertification will allow the Exchange board to change the baseline certification processes in future years 10