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Group Health Core Spring 2019 > New Lists > Flashcards

New Lists Flashcards

1
Q

Categories of approved and/or pending Section 1115 Medicaid waivers

A
  1. Alternative methods to expand Medicaid under the ACA’s Medicaid expansion
  2. Eligibility and enrollment requirements
  3. Work requirements to be eligible for coverage
  4. Benefit restrictions (e.g., copay limits)
  5. Behavioral health coverage changes (e.g., enhanced coverage for target populations)
  6. Delivery system reform initiatives (e.g., tying provider incentive payments to performance goals)
  7. Delivery of Medicaid long-term services and supports through capitated managed care
  8. Responding to public health emergencies
  9. Providing coverage for other targeted groups

WELDER BET

(Section 1115 Medicaid demonstration waivers)

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2
Q

What to watch for in Section 1115 waivers going forward

A
  1. What does research or experience in other states show?
  2. What populations are affected and will it change enrollment?
  3. What are the administrative costs and challenges?
  4. What is the process to receive public input
  5. What are the requirements for reporting and evaluating?

ReCIPE

(Section 1115 Medicaid demonstration waivers)

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3
Q

Revised CM/S section 1115 waiver approval criteria

A
  1. Improve access to high-quality, person-centered services with positive health outcomes
  2. Promote Medicaid’s sustainability over the long term
  3. Support strategies that promote upward mobility and greater independence
  4. Strengthen incentive structures that promote responsible decision making
  5. Enhance alignment between Medicaid policies and commercial health insurance
  6. Advance delivery system and payment models to strengthen provider network capacity

MANICS

(Section 1115 Medicaid demonstration waivers)

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4
Q

Specific requirements from the revised NAIC Actuarial opinion instructions

A
  1. The appointments by the company’s board of directors of a qualified health actuary. This actuary must report annually to the board or the audit company
  2. A process to request exemptions from having to file an actuarial opinion
  3. The use of a checkbox section to indicate whether the opinion is unqualified, qualified, adverse, or inconclusive
  4. Expansion of the scope of the Actuarial opinion to include specific Actuarial items presented as assets in the annual statement
  5. The definition of prescribed language as opposed to suggested language in the prior instructions with any modification or deviations notes within a checkbox section
  6. The requirement to reconcile underlying claim lag data to part 2b of the underwriting and investment exhibit
  7. A supporting Actuarial memorandum

U CAMELS

(Revised ASO Instructions for the NAIC Health Annual Statement)

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5
Q

The classifications of an Actuarial opinion

A
  1. Qualified - results from a situation where all liabilities are good and sufficient except for specifically defined items
  2. Adverse - the opinion arises when the actuary determines that the reserves and liabilities are not good and sufficient
  3. Inconclusive - this happens when the actuary is unable to form an opinion due to deficiencies in data, analysis, assumptions, or related information
  4. Unqualified - this is when all liabilities are deemed good and sufficient by the actuary

(Revised ASO Instructions for the NAIC Health Annual Statement)

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6
Q

Sections to include in the body of the Actuarial opinion

A
  1. Table of key indicators - alerts the reader to the opinion, changes in prescribed wording, and deviations from ASOPs
  2. Identification section - identifies the actuary
  3. Scope section - shows the actuary has checked assumptions and methods used and identifies subjects on which an opinion is to be expressed
  4. Reliance section - identifies anyone the actuary relied upon
  5. Opinion section - clearly shows the opinion
  6. Relevant comments - allows the actuary to further explain any circumstances, concerns, or issues

OR RISK

(Revised ASO Instructions for the NAIC Health Annual Statement)

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7
Q

Items to be considered for inclusion in the actuarial memorandum to show how conclusions were reached

A

In an actuarial statement of opinion the following will help another actuary understand how conclusions were reached

  1. Data reconciliation
  2. Claim triangles/lags
  3. Trend analysis
  4. Development of assumptions
  5. Other studies performed

TARTS

(Revised ASO Instructions for the NAIC Health Annual Statement)

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8
Q

For an actuarial statement of opinion the following items are required to be included in the actuarial memorandum

A
  1. An exhibit that ties to the annual statement
  2. Documentation of the reconciliation from data used for analysis to the Underwriting and Investment Exhibit Part 2B, with explanations of the drivers of the differences
  3. Any other follow-up studies documenting the prior years’ claim liability and claim reserve run-off as considered necessary by the actuary
  4. Documentation of the assumptions used for contract reserves with any changes in assumptions from previous valuations and support of any margin included in the reserves

PEAR

(Revised ASO Instructions for the NAIC Health Annual Statement)

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9
Q

The purpose of contract reserves

A
  1. A reserve held because future claims are greater than the future net premiums
  2. Needed to prefund the expected increases in claims in later years
  3. These types of reserves are needed for long-term insurance policies

(Practices for Preparing Health Contract Reserves)

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10
Q

GAAP guidance for setting contract reserves

A
  1. Divides insurance into two main categories: short term and long term
  2. For long term contracts the insurer will hold a contract or benefit reserve
  3. Generally prohibits insurers from establishing a benefit reserve for short term contracts
  4. Benefit reserves should include a provision for adverse deviation
  5. Assumptions used to initially calculate the reserve are locked-in
  6. If a deficiency exists, the original assumptions are “unlocked” and updated

LT ST Dev Locked Unlocked

(Practices for Preparing Health Contract Reserves)

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11
Q

SAP guidance for setting contract reserves

A
  1. SAP uses four classes: life, accident and health (A&H), property and casualty (P&C), and deposit-type
  2. A&H contracts are defined to include unearned premium reserves and contract reserves
  3. Reserve required for contracts when the future claims are greater than the future premiums except:
    - when contracts cannot be continued after one year from issue
    - when a years’ worth of premium is intended to cover that year’s claims without prefunding of future cash flows
  4. Uses prescribed methodologies and assumptions for computing minimum allowable reserves
  5. GAAP allows for a greater freedom to select methods and assumptions and must include provisions for adverse deviation

CARP G

(Practices for Preparing Health Contract Reserves)

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12
Q

Recommendations for determining SAP and GAAP contract reserve assumptions

A
  1. Under SAP:
    - Determine a liability under moderately adverse, but not excessive, conditions
    - Many actuaries believe that the SAP reserve should be greater than the best estimate
    - At least as great as the amount determined using the state prescribed methodology and assumptions
  2. Under GAAP:
    - include provision for adverse deveiation
    - Unlike SAP, no prescribed assumptions
    - GAAP reserves should be less than SAP but greater than best estimate

(Practices for Preparing Health Contract Reserves)

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13
Q

Methods that are used for contract reserves for SAP vs GAAP

A
  1. Under either method, if the contract reserves are deficient additional reserves may be required as determined by a gross premium valuation
  2. For SAP, the minimum reserve standard is a preliminary term method
  3. For GAAP, they use the net level premium method

APT

(Practices for Preparing Health Contract Reserves)

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14
Q

Tax deductibility of health contract reserves and premium deficiency reserves

A
  1. In general, contract reserves are tax deductible for insurance companies if the contract is noncancelable or guaranteed renewable
  2. Several assumptions have specific guidelines that must be followed when calculating a tax reserve
  3. The method is defined as the two-year preliminary term except for the LTC contracts which are based on the one-year preliminary term
  4. Premium deficiency reserves are not tax deductible
  5. The tax reserve may never be greater than the statutory reserve actually held

S2D GG

(Practices for Preparing Health Contract Reserves)

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15
Q

Situations for which insurers are allowed to unlock GAAP assumptions

A
  1. When a gross premium valuation reveals a premium deficiency
  2. When a future projection by calendar year reveals a pattern of profits followed by losses
  3. When internal replacement occurs

GRP

(Practices for Preparing Health Contract Reserves)

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16
Q

Important aspects of GAAP loss recognition testing

A
  1. Applies to all business in force
  2. Timing is not specified but it should be performed periodically and when experience deviates unfavorably from expected
  3. Tests should be performed without provisions for adverse deviation
  4. Once testing results in corrective action tests must repeat on future valuation dates

(Practices for Preparing Health Contract Reserves)

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17
Q

Important aspects of GAAP DAC recoverability testing

A
  1. Applies to all new business
  2. Occurs in the first contract year
  3. Testing excludes non deferrable and overhead costs
  4. Test first with provisions for adverse deviation (PAD), if fail remove PAD and test again
  5. If testing after removing the PAD fails then move to unlock GAAP assumptions

(Practices for Preparing Health Contract Reserves)

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18
Q

Important aspects of SAP gross premium valuation

A
  1. Should be done when a company has concern about reserve [a]dequacy
  2. The valuations are often performed at aggregate levels of [l]ines of businesss
  3. All [e]xpenses should be considered
  4. Generally believed to be based on assumptions that would produce an adequate reserve under [m]oderately adverse conditions

MEAL

(Practices for Preparing Health Contract Reserves)

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19
Q

Important aspects of the ACA’s risk adjustment program

A
  1. Intended to even out the risk in the insured population in the individual and small group market
  2. Risk scores for a company will be compared to the market average
  3. Insurers with below-average risk scores will compensate, or transfer to, those with above average risk scores
  4. Risk scores will need to be estimated before experience is complete
  5. Transfer estimates will need to be accrued in the current plan year and reflected in current financial statements prior to the actual settlement
  6. Estimated to be as much as +/- 15% of health plan premiums with smaller insurers possibly seeing +/-40%

(ACA’s impact on financial statements)

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20
Q

Important aspects of the ACA’s reinsurance program

A
  1. Reimburses health plans for high-cost individuals in the individual commercial market
  2. Payment in 2014 was expected to be 80% of claims from a single claimant for annual amounts between $45K and $250K. The parameters changed in ‘15 and ‘16
  3. Estimating this reimbursement timing brought added complexity. Large claims have longer runout periods
  4. This was a subsidy since the fee was paid by all markets, but only the individual market received recoveries
  5. Since the payment happened in the middle of the subsequent year, there were cash flow challenges for some insurers
  6. As with many types of receivables, there was different reporting guidance from various standards (i.e., GAAP and STAT)
  7. The fee funding the program ended in 2016 with the program
  8. The fee was collected based on member counts, and there were various methods for plan sponsors to “count” these members

(ACA’s impact on financial statements)

21
Q

Important aspects of the ACA’s risk corridor program

A
  1. Ended in 2016
  2. Shared in claims costs deviation from a targeted amount
  3. It was for issuers of qualified health plans (QHPs) in the individual and small group markets
  4. Risk corridors kicked in when claims varied by 3% or more from the target claims amount, where excess claims were initially shared 50% with the federal government
  5. Beyond an 8% variation from target, excess claims were shared 80% with the federal government
  6. This program was considered highly complex in terms of estimation and even unexpected nuances
  7. Impact estimates were as much as +/- 25% of premiums

(ACA’s impact on financial statements)

22
Q

Important aspects of the ACA’s premium subsidies program

A
  1. Available to individuals and families whose incomes are between 100% and 400% of the FPL
  2. Premium subsidy payment should be received monthly before the month of coverage
  3. Annual retroactive adjustments will be made to the government for members who terminate coverage prematurely
  4. Subsidies receive by the insurer prior to the start of coverage should be recorded as an unearned premium, becoming “earned” when the coverage becomes effective

(ACA’s impact on financial statements)

23
Q

Important aspects of the ACA’s cost-sharing reduction (CSR) subsidies program

A
  1. Members with incomes between 100% and 250% of the FPL are eligible for this permanent program
  2. Members mush choose a silver plan to qualify
  3. The cost-sharing subsidy may be in addition to the premium subsidy
  4. Insurers will enroll qualified members in cost-share-reduced plan designs
  5. The federal government will reimburse the insurer the difference between what the member paid in the enhanced plan design and what would have been paid in the standard silver plan
  6. The federal government will provide insurers of these members with prospective payments throughout the year on a monthly basis
  7. Reconciliation occurs in the following year
  8. As insurers are asked to generate effective cost-sharing parameters by adjudicating reduced claims through the standard silver plan design, they may run into credibility issues. There are alternative approaches in those cases

(ACA’s impact on financial statements)

24
Q

Description of the health insurance provider fee

A
  1. The permanent excise tax on insurers is nondeductible tax on income
  2. It is based on the prior year’s collected premiums
  3. The liability should be recognized on Jan 1 of the year it is paid
  4. The corresponding asset seems to be recognized differently between GAAP and STAT
  5. The fee is monthly, with annual retroactive reconciliations
  6. The fee was approximately 2% of premiums in 2014, and increases in subsequent years

(ACA’s impact on financial statements)

25
Q

Types of statements of actuarial opinion

A
  1. Unqualified opinion
    - for NAIC Health Annual Statement, the reserve amount makes good and sufficient provision for all unpaid claims and other actuarial liabilities and that obligations are covered even under moderately adverse conditions
    - In other circumstances, says the liability and asset amounts are reasonable for the intended purpose
  2. Adverse opinion
    - For NAIC Health Annual Statement, says the aggregate amount established is not sufficient for the actuary to provide an unqualified opinion
    - In other circumstances, says the liabilities fall outside a reasonable range for the specified purpose
  3. Qualified opinion - issued when there are certain liabilities or assets that the actuary believes cannot be reasonably estimated or for which the actuary is unable to render an opinion
  4. Inconclusive opinion - issued when the actuary cannot reach a conclusion due to deficiencies or limitations in the data, analyses, assumptions, or related information

(ASOP #28)

26
Q

Information to include in a statement of actuarial opinion

A
  1. The [w]ords “statement of actuarial opinion” in the title
  2. The intended [u]sers
  3. The intended [p]urpose
  4. The [l]iabilities being opined upon
  5. The stated [b]asis of the amounts presented
  6. The [s]cope of the analysis underlying the opinion and the review date if different from the date the opinion is signed
  7. The [t]ype of opinion

PLUS BTW

(ASOP #28)

27
Q

Prescribed benefit classifications for MHPAEA

A

When parity testing MH/SUD benefits the minimum prescribed benefits classification levels that must be used:

  1. IP, IN
  2. IP, OON
  3. OP, IN
  4. OP, OON
  5. ER
  6. Pharmacy

(Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act)

28
Q

Steps to show Quantitative Treatment Limitations (QTLs) satisfy parity requirements for MH/SUD benefits

A
  1. Determine if the QTL applies to “substantially all” (at least 2/3s) of medical/surgical benefits
  2. Apply the “predominant” test
  3. If a single level of QTL applies to over half the benefits subject to the QTL in that classification, it is considered the predominant benefit level and the MH/SUD benefit must be richer than that level
  4. If there is no single level that applies to more than half of the medical/surgical benefits subject to the QTL in a benefits classification, the health plan can combine levels to get over half of the benefits
  5. After combining benefits, the QTL that is the least restrictive will be the “predominant” benefit level used to test the MH/SUD benefits

(Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act)

29
Q

Requirements for applying a Nonquantitative Treatment Limitation (NQTL) to MH/SUD benefits

A
  1. The NQTL is comparable to an NQTL imposed on medical/surgical benefits and
  2. The NQTL is applied no more stringently to the MH/SUD benefits than to the medical/surgical benefits

(Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act)

30
Q

Common NQTLs that are found in health plans

A
  1. Utilization management practices
  2. Medical necessity criteria
  3. Experimental treatment exclusions
  4. Primary care physician or other gatekeeping
  5. Approval of formulary drugs
  6. Placement of drugs on formulary tiers
  7. Generic substitution/therapeutic interchange or substitution
  8. Pharmacy benefit management protocols
  9. Network tier design
  10. Standards for provider admission to participate in a network
  11. Plan methods for determining UCR charges
  12. Fail-first policies (step-therapy protocols)
  13. Employee assistance plans (EAPs)

(Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act)

31
Q

Health plans required to meet the MHPAEA requirements

A
  1. Fully insured employer plans
  2. Self-funded employer plans
  3. Non-grandfathered plans in the individual and small-group markets

(Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act)

32
Q

Health plans that are specifically excluded from MHPAEA

A
  1. Small private employers that are not required by the ACA to provide EHBs
  2. Plans that met increased cost exemption requirements
  3. Self-funded state or local governmental plans that request exemption
  4. Medicare plans
  5. Veteran Affairs and TriCare plans

VEEP M

(Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act)

33
Q

Required components of a regulatory compliance program for MHPAEA

A

To adhere to provisions specific to MHPAEA, Core 4 of URAC’s standards requires that the health plan implement a regulatory compliance program that:

  1. Tracks applicable laws and regulations
  2. Ensures the organization’s compliance
  3. Responds to detected problems and takes corrective action

(Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act)

34
Q

Controls a health plan must implement to monitor adherence to MHPAEA

A

These Compliance Program Internal Controls are needed in order to effectively monitor adherence to the laws and regulations of MHPAEA

  1. Designating a compliance officer
  2. Periodic review and update of the compliance program in the organization’s training
  3. Periodic internal monitoring and auditing
  4. Periodic review and analysis to determine any changes in
    - Benefits
    - Policies
    - Procedures
    - Utilization management protocols that impact compliance
    - Communication to delegated contractors regarding changes impacting compliance
  5. Performance of a thorough review of state and federal laws and regulations related to privacy and security

CAPPO

(Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act)

35
Q

Purpose of the ACA’s 1332 waivers

A
  1. Purpose is to allow states to undertake different approaches to achieving the ACA’s core goals
  2. Relative to status quo the waivers must:
    - Be at least as successful at providing access to affordable good quality health insurance coverage
    - do so at the same or lower cost to the federal government
    - pass the guardrail tests that show the above requirements were met

AM ACT

(Understanding the ACA’s state innovation (1332) waivers)

36
Q

Guardrails used to demonstrate 1332 waiver standards

A
  1. Provide benefits as comprehensive as the EHBs
  2. Provide cost share protections and coverage at least as affordable as those in the marketplace
  3. Ensure a comparable number of people have health coverage
  4. Not increase the federal deficit

(Understanding the ACA’s state innovation (1332) waivers)

37
Q

CMS guidance for passing the guardrails for the 1332 waiver

A
  1. The waiver must not result in fewer individuals covered with benefits at least as comprehensive as the benchmark for all ten EHB categories
  2. The waiver cannot result in more uninsured relative to the current law
  3. CMS evaluates affordability on a high level average and also at more detailed levels of individuals
  4. Members must have coverage with an actuarial value of at least 60% and an out-of-pocket maximum that complies with ACA requirements
  5. The waiver review focuses on vulnerable populations: low income individuals, seniors, and the very sick
  6. Applications must show how all requirements were met and how they differ from the current
  7. The initial duration of a waiver is five years, but the state must demonstrate that it will be deficit neutral to the federal government over ten years
  8. Applications must describe models used to demonstrate deficit neutrality, showing the following:
    - Data sources
    - Data quality
    - Key assumptions
    - Key parameters
    - Other supporting documentation of the actuarial and economic analysis

VAN CURVS D2K2O

(Understanding the ACA’s state innovation (1332) waivers)

38
Q

Material changes to the risk adjustment program since 2014

A
  1. Allowing certain high-cost pharmaceuticals to influence risk scores for certain conditions
  2. Risk adjustment is no longer systematically overstated by approximating non-claim related costs
  3. Adjustments were made for short-duration members (these members have a disproportionate share in costs)
  4. A large claim reinsurance model was embedded within the risk adjustment program
  5. For 2018, risk scores have been updated with new weights based on updated data
  6. CMS has granted states the right to cut the transferred percentage to as low as 50% of what it would have been

(Recent policy changes under the ACA)

39
Q

Reasons that most CO-OPs were not successful

A
  1. Political dismantling of the risk corridor program
  2. Too much growth in relation to their capital
  3. Access to federal loans were halted due to the political climate

LPG

(Recent policy changes under the ACA)

40
Q

Concerns for allowing insurance companies to sell across state lines

A
  1. Provider network inadequacy
  2. Level playing field for insurers’ operational requirements
  3. A race to the bottom in terms of benefits and/or state regulations
  4. Ensuring premiums are reasonable in relation to benefits

(Recent policy changes under the ACA)

41
Q

Changes in the ACA that affect rate setting

A
  1. The child age gender factor was initially set exceptionally low at .635, but in 2018 it has increased (tiered across brackets)
  2. CMS proposed reducing MLR standards substantially by adding carrier favorable adjustments
  3. CMS has also proposed allowing state regulators to petition for a reduction in the federal MLR threshold applicable in their state
  4. For plan years 2019 and beyond, CMS is proposing to move the premium increase that triggers a rate review from 10 to 15%
  5. IF an enrollee attempts to rejoin the individual market with the same carrier, the carrier ay collect any past due premium owed from the past 12 months if it is in the contract language

(Recent policy changes under the ACA)

42
Q

Plan design, covered services, and operational rule changes/proposals to the ACA

A
  1. In plan year 2018, metal levels plans have wider ranges of acceptable actuarial values
  2. Proposed 2019 changes would provide states more flexibility in selecting EHB benchmarks
  3. Starting in plan year 2018, carriers must count out-of-network cost sharing towards the in-network out-of-pocket maximum if the consumer had accessed those services at an in-network setting
  4. Starting with plan year 2018, CMS requires that carriers must sell silver and gold plas in order to be allowed to sell via the exchange
  5. In the fall of 2017, the current administration is expanding the types of employers that can opt out of providing contraception benefits
  6. Allowing carriers to reject premium payments from third party payers that may be offering self-interested advice to the enrollee

COMET G

(Recent policy changes under the ACA)

43
Q

Functions provided by the federal small group exchange (SHOP) for 2018 and beyond

A

The federal government will no longer operate the SHOP as it had in the past and this is a list of what functions remain, with all other current functions being terminated

  1. Showcasing plans and prices
  2. Performing plan certifications
  3. Providing a call center
  4. Processing employer appeals
  5. Assisting with small business tax credits

(Recent policy changes under the ACA)

44
Q

New tax-favorable opportunity for small employers to provide health insurance due to the 21st Century CURES Act

A
  1. Employers can create and fund an account allowing employees to use the funds to purchase coverage on the individual market
  2. This is good for lower-compensated employees who might also receive subsidies in the individual market

(Recent policy changes under the ACA)

45
Q

How the ACA risk adjustment program plays a critical role in the market

A
  1. Reducing the potential for adverse selection
  2. Promoting a level playing field
  3. Promoting stability and affordability for consumers

(The ACA risk adjustment program)

46
Q

Important findings from various reports on the premium stabilization programs

A
  1. Transitional reinsurance and permanent risk adjustment programs are functioning smoothly
  2. Paid claims were strongly correlated with risk scores, risk adjustment, and risk transfers
  3. Smaller and larger insurers received similar risk adjustment transfers on average as a percentage of permium
  4. The risk adjustment program compressed loss ratio differences among insurers
  5. The program redistributed funds from plans with lower-risk members to plans with higher-risk members
  6. Virtually all insurers successfully submitted the data necessary to calculate the risk adjustment payment transfers

DR CFP

(The ACA risk adjustment program)

47
Q

Potential changes to the risk adjustment model

A
  1. Incorporating prescription drug data
  2. Better reflecting the cost of partial year enrollees
  3. Recalibrating the model risk weights to better reflect the experience in the exchange
  4. Making adjustments to the payment transfer formula

FREE

(The ACA risk adjustment program)

48
Q

Covered ASOPs

A
  1. ASOP #6 - Measuring Retiree Group Benefit Obligations and Determining Retiree Group Benefits Program Periodic Costs or Actuarially Determined Contributions
  2. ASOP #8 - Regulatory Filings for Health Plan Entities
  3. ASOP #21 - Responding to or Assisting Auditors or Examiners in Connection with Financial Statements for All Practice Areas
  4. ASOP #23 - Data Quality
  5. ASOP #25 - Credibility Procedures
  6. ASOP #26 - Compliance with Statutory and Regulatory Requirements for the Actuarial Certification of Small Employer Health Benefit Plans
  7. ASOP #28 - Statements of Actuarial Opinion Regarding Health Insurance Liabilities and Assets
  8. ASOP #41 - Actuarial Communications
  9. ASOP #49 - Medicaid Managed Care Capitation Rate Development and Certification
  10. ASOP #50 - Determining Minimum Value and Actuarial Value Under the ACA

Group Health Core Spring 2019 (2 decks)

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