pennsylvania blueprint package - state exchange

8/9/2019 Pennsylvania Blueprint Package - State Exchange

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Centers for Medicare & Medicaid ServicesCenter for Consumer Information and Insurance Oversight

PennsylvaniaBlueprint Package

Exchange Type: State Exchange

Application Percentage Complete: 100%

Application Status: Complete

PDF Generated on: June 1, 2015, 5:02 pm EST


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Contents

1.0 - Legal Authority and Governance .......................................................................................... 2

2.0 - Consumer and Stakeholder Engagement and Support ................................................... 11

3.0 - Eligibility and Enrollment ................................................................................................... 34

4.0 - Plan Management ................................................................................................................. 766.0 - SHOP ...................................................................................................................................... 99

7.0 - Organization and Human Resources .............................................................................. 109

8.0 - Finance and Accounting .................................................................................................... 113

9.0 - Technology .......................................................................................................................... 116

10.0 - Privacy and Security ........................................................................................................ 119

11.0 - Oversight, Monitoring, and Reporting .......................................................................... 124

12.0 - Contracting, Outsourcing, and Agreements ............................................................... 129

13.0 - State Partnership Exchange Activities ......................................................................... 130


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1.0 - Legal Authority and Governance (100% Completed)

1.1The State has enabling authority to operate an Affordable Insurance Exchange, including a Small BusinessHealth Options Program (SHOP), compliant with Affordable Care Act Section 1321(b) and implementingregulations.

Completed

Yes No

Expected Completion Date

07/10/2015

Supporting Documents

Copy of current law and/or regulation that indicates that the State has

necessary legal authority to establish an Exchange or that establishes theExchange.

Not Applicable HHS Approval Letter for Waive-Out

Approval Letter Date:

Document Title Document Filename Size Date Uploaded

__OR__ Other legislation or general authority (e.g., Executive Order) that the

State has determined provides the necessary legal authority to establish anExchange.

Note: If the SHOP was separately authorized from the Exchange, pursuant to Affordable Care Act Â§ 1321(b), provide documentation demonstrating that theState has enabling authority to establish and operate a SHOP.




__AND__ If authority is not clear on its face, provide a Statement from the legalcounsel of the office of the applicant, the Governorâs legal counsel, or theStateâs Attorney Generalâs Office (correspondence or a formal legalopinion) certifying that the State is authorized to establish an Exchange underState law.




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1.2The Exchange has been established in compliance with Affordable Care Act 1311(d) and 45 CFR 155.110. If State agency, please proceed to Section 2.

Completed

Yes No


07/10/2015


Brief description of governance structure (e.g., State agency, nonprofitorganization). If State agency, please proceed to Section 2.

Brief Description

We intend to house the Exchange in the PennsylvaniaDepartment of Human Services, an existing stateagency which runs the PA Medicaid program. This willbe in the draft legislation that we share with thelegislature.

HHS Approval Letter for Waive-Out



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1.2aThe Exchange board and governance structure has been established in compliance with Affordable Care Act1311(d) and 45 CFR 155.110.

Not Applicable

Completed

Yes No


Brief description of board composition, including board membersâ affiliationsand any consumer representation. Note any differences in board compositionand governance structure for SHOP.

Brief Description




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1.2bThe Exchange has a formal, publicly-adopted charter or bylaws.

Not Applicable

Completed

Yes No

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1.2cThe Exchange has established governance policies in compliance with 45 CFR 155.110(d) and obtained conflictof interest disclosures from board members, including disclosures of financial interest.

Not Applicable

Completed

Yes No

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1.2dThe governing board has at least one voting member who is a consumer representative, and does not have amajority of voting representatives with a conflict of interest.

Not Applicable

Completed

Yes No

8


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1.2eThe majority of the voting members have relevant experience in health benefits administration, health carefinance, health plan purchasing, health care delivery system administration, public health, or health policy issuesrelated to the individual and small group markets and the uninsured.

Not Applicable

Completed

Yes No

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1.2f The Exchange holds regular, public governing-board meetings that are announced in advance.

Not Applicable

Completed

Yes No

10


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2.0 - Consumer and Stakeholder Engagement and Support (100% Completed)

2.1The Exchange has developed and implemented a stakeholder consultation plan and has consulted with, and willcontinue to consult with, consumers, small businesses, State Medicaid and CHIP agencies, agents/brokers,employer organizations, and other relevant stakeholders as required under 45 CFR 155.130.

Completed

Yes No


09/30/2015


Brief description of the stakeholder consultation plan that addresses how

consultation will occur on an ongoing basis with consumers, small businesses,State Medicaid and CHIP agencies, agents/brokers, employer organizations,and other relevant stakeholders as required under 45 CFR 155.130.

Brief Description

In the third quarter of 2015, we propose to convenean advisory group with two subgroups, one on planmanagement and delivery system reform, and one onmarketing, outreach, and enrollment assistance.Initially, the advisory group will meet on a mon...

HHS Approval Letter for Waive-Out Approval Letter Date:


Work Plan

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2.2 Applicable only to States with Federally-recognized Tribes: The Exchange, in consultation with theFederally-recognized Tribes, has developed and implemented a Tribal consultation policy or process, which hasbeen submitted to HHS.

Not Applicable

Completed

Yes No

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2.3The Exchange provides culturally and linguistically appropriate outreach and educational materials to the public,including auxiliary aids and services for people with disabilities, regarding eligibility and enrollment options,program information, benefits, and services available through the Exchange, the Insurance AffordabilityProgram(s), and the SHOP.

In addition, the Exchange has an outreach plan for populations including: individuals, entities with experience infacilitating enrollment such as agents/brokers, small businesses and their employees, employer groups, health

care providers, community-based organizations, Federally-recognized Tribal communities, advocates forhard-to-reach populations, and other relevant populations as outlined in 45 CFR 155.130.

Completed

Yes No


10/01/2015


Brief description of the outreach plan(s) and targeted efforts that address eachpopulation or type of stakeholder, including those identified in 45 CFR 155.130.

Brief Description



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2.3aThe Exchange has developed and provides culturally and linguistically appropriate outreach and educationalmaterials and auxiliary aids and services to people with disabilities (including information in alternate format),regarding eligibility and enrollment options, program information, benefits, and services available through theExchange, SHOP, and other Insurance Affordability Programs, as required in 45 CFR 155.205(c).

Completed

Yes No


10/01/2015

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2.3bThe Exchange has an outreach plan for populations including: individuals, entities with experience in facilitatingenrollment such as agents/brokers, small businesses and their employees, employer groups, health careproviders, community-based organizations, Federally-recognized Tribal communities, advocates forhard-to-reach populations, and other relevant populations as outlined in 45 CFR 155.130.

Completed

Yes No


10/01/2015

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2.4The Exchange provides for the operation of a toll-free telephone hotline (call center) to respond to requests forassistance from the public, including individuals, employers, and employees, at no cost to the caller as specifiedby 45 CFR 155.205(a).

Completed

Yes No


10/26/2015


Brief description of the call centerâs strategy for managing call volume, planfor translation services, and toll-free telephone number.

Brief Description




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2.4aThe Exchange provides for the operation of a toll-free telephone hotline (call center) which acts as a central lineto handle seamless application support, coordinates with other Insurance Affordability Program(s) and withother State and Federal agencies, and responds to requests for assistance from the public, including individuals,employers, and employees, at no cost to the caller as specified by 45 CFR 155.205(a).

Completed

Yes No


10/26/2015

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2.4bThe Exchange provides translation and oral interpretation services and auxiliary aids and services to the public,including individuals, employers, and employees, at no cost to the caller.

Completed

Yes No


10/26/2015

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2.4cThe Exchange provides adequate training and resources to operate the call center, including an operating planand procedures.

Completed

Yes No


10/23/2015

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2.5The Exchange has established and maintains an up-to-date Internet Web site that provides timely and accessibleinformation on Qualified Health Plans (QHPs) available through the Exchange, Insurance AffordabilityProgram(s), and the SHOP, and includes requirements specified in 45 CFR 155.205(b).

Completed

Yes No


10/19/2015


Internet Web site URL address for the Exchange and the SHOP, if different.




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2.5aThe Exchange has established and maintains an up-to-date Internet Web site that provides timely and accessibleinformation on Qualified Health Plans (QHPs) available through the Exchange, Insurance AffordabilityProgram(s), and the SHOP, and includes requirements specified in 45 CFR 155.205(b).

Completed

Yes No


10/19/2015

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2.5bThe Exchange's Internet Web site provides information on premium and cost-sharing, QHP comparison, metallevel of QHP coverage, transparency of coverage measures, and a provider directory.

Completed

Yes No


10/12/2015

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2.5cThe Exchange's Internet Web site provides information in a manner that is accessible to individuals withdisabilities and individuals with limited English proficiency, as required in 45 CFR 155.205(b) and (c).

Completed

Yes No


10/19/2015

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2.6The Exchange has established or has a process in place to establish and operate a Navigator program that isconsistent with the applicable requirements of 45 CFR 155.210, including the development of training andconflict of interest standards, and adherence to privacy and security standards specified in 45 CFR 155.210 and45 CFR 155.260.

Completed

Yes No


08/01/2016


Brief description of Exchangeâs plan to operate a Navigator program,including documentation outlining the Exchangeâs progress in developingconflict of interest and training standards; how it will ensure Navigators areappropriately trained and meet the Exchangeâs conflict of interest, privacyand security standards; and a timeline and strategy for funding for theNavigator program and making the program fully operational.

Brief Description




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2.6aThe Exchange has established or has a process in place to establish and operate a Navigator program that isconsistent with the applicable requirements specified in 45 CFR 155.210 and 45 CFR 155.260.

Completed

Yes No


08/01/2016

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2.6bThe Exchange has a plan for the ongoing funding of an Exchange Navigator program, in order to award at leasttwo (2) types of entities, one of which is a community or consumer-focused organization or non-profit entity.Grant agreements ensure that Navigator grantees (âNavigatorsâ) will conduct the five (5) duties outlined in45 CFR 155.210(e).

Completed

Yes No


12/31/2015

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2.6cThe Exchange has begun to develop training and conflict of interest standards for Navigators.

Completed

Yes No


05/17/2016

Work Plan


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2.7If applicable: The Exchange has established an in-person assistance program distinct from the Navigatorprogram and has a process in place to operate the program consistent with the applicable requirements of 45CFR 155.20(c), (d), and (e).

Not Applicable

Completed

Yes No


08/15/2015


Brief description of Exchangeâs plan to operate an in-person assistanceprogram distinct from the Navigator program, which provides in-personassistance to consumers, including documentation outlining the Exchangeâsprogress in developing conflict of interest and training standards; how it willensure in-person assistance program staff are appropriately trained and meetthe Exchangeâs conflict of interest, accessibility, and privacy and securitystandards; and a timeline and strategy for funding for the in-person assistanceprogram and making the program fully operational.

Brief Description

For the numerous organizations designated ascertified application counselors (CACs) by thefederal government as of June 1, 2015, DHS willextend that designation through June 1, 2016 if theorganizations register with the state and pro...




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2.8If applicable: If the State permits activities by agents and brokers pursuant to 45 CFR 155.220(a), the Exchangehas clearly defined the role of agents and brokers including evidence of licensure, training, and compliance with45 CFR 155.220(c)-(e). The Exchange will have agreements with agents/brokers consistent with 45 CFR 155.220(d), which address agent/broker registration with the Exchange, training on QHP options and Insurance Affordability Program(s), and adherence to privacy and security standards, as specified in 45 CFR 155.260.

Not Applicable

Completed

Yes No


If applicable: Brief description of the strategy, including the Exchangeâscompensation policy for agents/brokers, including web brokers, as it relates to

their enrollment of individuals through the Exchange.

Brief Description




__AND__ If applicable: Brief description of the Exchangeâs policy forensuring compliance with 45 CFR 155.220(d) and (e), including how it willensure agents/brokers are appropriately trained and meet the Exchangeâsprivacy and security standards.

Brief Description




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2.8aIf applicable: The Exchange has a process to verify that agents/brokers are in compliance with State law,including licensure requirements consistent with 45 CFR 155.220(e).

Not Applicable

Completed

Yes No

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2.9If applicable: If the State permits activities by agents and brokers pursuant to 45 CFR 155.220(a), the Exchangehas clearly defined the role of web brokers including evidence of licensure, training, and compliance with 45CFR 155.220(c)-(e). Specifically, the Exchange has agreements with web brokers consistent with 45 CFR 155.220(d), which address agent/broker registration with the Exchange, training on QHP options and Insurance Affordability Program(s), and adherence to privacy and security standards, as specified in 45 CFR 155.260.

Not Applicable

Completed

Yes No


If applicable: Brief description of how the Exchangeâs Internet Web site willinterface with web brokersâ Web sites.

Brief Description




__AND__ If applicable: Brief description of Exchangeâs policy for ensuringcompliance with 45 CFR 155.220(c)(3),(d) and (e), including how it will ensureweb brokers are appropriately trained and meet the Exchangeâs privacy andsecurity standards.

Brief Description




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2.9aIf applicable: The Exchange has a process to verify that web brokers are in compliance with State law includinglicensure requirements consistent with 45 CFR 155.220(e).

Not Applicable

Completed

Yes No

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2.9bIf applicable: The Exchange has agreements with web brokers, consistent with 45 CFR 155.220(d), whichaddress web broker registration with the Exchange, training on QHP options and Insurance AffordabilityProgram(s), and adherence to privacy and security standards, as specified in 45 CFR 155.260.

Not Applicable

Completed

Yes No

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3.0 - Eligibility and Enrollment (100% Completed)

3.1The Exchange has developed and will use an HHS-approved single, streamlined application for the individualmarket â or will use the HHS-developed application â to determine eligibility and collect information that isnecessary for enrollment in a QHP for the individual market and for Insurance Affordability Programs as

specified in 45 CFR 155.405. The Exchange has developed and will use an HHS-approved application for SHOPor will use the HHS-developed application for SHOP employers and employees as specified in 45 CFR 155.730.

Completed

Yes No


09/03/2015


If applicable: State-developed single-streamlined application to determineeligibility for the individual market.




__AND__ If applicable: State-developed single-streamlined application todetermine eligibility for the SHOP.




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3.1a1The Exchange has developed and will use a HHS-approved single, streamlined application for the individualmarket to determine eligibility and collect information that is necessary for enrollment in a QHP and forInsurance Affordability Programs as specified in 45 CFR 155.405. OR

Not Applicable

Completed

Yes No

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3.1a2The Exchange will use the HHS-developed single, streamlined application for the individual market to determineeligibility and collect information that is necessary for enrollment in a QHP and for Insurance AffordabilityPrograms as specified in 45 CFR 155.405.

Not Applicable

Completed

Yes No

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3.1b1The Exchange has developed and will use HHS-approved applications for SHOP employers and employees asspecified in 45 CFR 155.730. OR

Not Applicable

Completed

Yes No

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3.1b2The Exchange will use the HHS-developed applications for SHOP employers and employees as specified in 45CFR 155.730.

Not Applicable

Completed

Yes No

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3.2The Exchange has developed and documented a coordination strategy with other agencies administeringInsurance Affordability Programs and the SHOP that enables the Exchange to carry out the eligibility andenrollment activities.

Completed

Yes No


09/03/2015


Brief description of the Exchangeâs coordination strategy with otheragencies administering Insurance Affordability Programs and the SHOP relatedto eligibility and enrollment activities.

Brief Description

PA elects to leverage the Federal platform.




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3.3The Exchange has the capacity to accept and process applications, updates, and responses to redeterminationsfrom applicants and enrollees, including applicants and enrollees who have disabilities or limited Englishproficiency, through all required channels, including in-person, online, mail, and phone.

Completed

Yes No


11/01/2015

Test Documents

Results of State execution of HHS-developed test scenarios (please refer to theTest Scenarios Activity Area in SERVIS for more information).

Approval Letter Date: HHS Approval Letter for Waive-Out

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Summary of Independent Verification & Validation (IV&V) of applicable systemcomponents


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Summary of results of State-developed testing


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3.3aThe Exchange has the capacity to accept and process applications, updates, and responses to redeterminationsfrom applicants and enrollees in-person.

Completed

Yes No


09/03/2015

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3.3bThe Exchange has the capacity to accept and process applications, updates, and responses to redeterminationsfrom applicants and enrollees online.

Completed

Yes No


09/03/2015

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3.3cThe Exchange has the capacity to accept and process applications, updates, and responses to redeterminationsfrom applicants and enrollees via mail.

Completed

Yes No


09/03/2015

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3.3dThe Exchange has the capacity to accept and process applications, updates, and responses to redeterminationsfrom applicants and enrollees via phone.

Completed

Yes No


09/03/2015

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3.3eThe Exchange has the capacity to conduct the activities set out in 3.3a â 3.3d for applicants and enrollees whohave disabilities or limited English proficiency.

Completed

Yes No


09/03/2015

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3.4The Exchange has the capacity to send notices, including notices in alternative formats and multiple languages;conduct periodic data matching; and conduct annual redeterminations and process responses in-person, online, via mail, and over the phone pursuant to 45 CFR 155, subpart D.

Completed

Yes No


09/03/2015


If the Exchange will conduct additional periodic data matching in accordancewith 45 CFR 155.330(d)(2), provide brief description of the data sources to beused.

Brief Description




Test Documents










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3.4aThe Exchange has the capacity to generate and send notices, including notices in alternative formats andmultiple languages, pursuant to 45 CFR 155, subpart D.

Completed

Yes No


09/03/2015

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3.4bThe Exchange has the capacity to conduct periodic data matching pursuant to 45 CFR 155, subpart D and act onthe results of the data matching.

Completed

Yes No


09/03/2015

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3.4cThe Exchange has the capacity to conduct annual redeterminations and process responses through all channelspursuant to 45 CFR 155, subpart D.

Completed

Yes No


09/03/2015

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3.5The Exchange has the capacity to conduct verifications pursuant to 45 CFR 155, subpart D, and is able toconnect to data sources, such as the Data Services Hub, and other sources as needed.

Completed

Yes No


09/03/2015


Comprehensive list of data sources that the State is connecting to orinterfacing with, including a description of the data types and informationassociated with each source (including data sources that are used as primary verification methods or are used when information is not reasonablycompatible).

Brief Description

PA elects to leverage the Federal platform.




__AND__ Brief description of how verifications will be conducted in thefollowing areas: residency, citizenship and immigration status, incarceration,household income, family/household size, whether an individual is an Indian,enrollment in an eligible employer-sponsored plan (if applicable), eligibility forqualifying coverage in an eligible employer-sponsored plan, and eligibility fornon-employer-sponsored minimum essential coverage. If applicable, describeany of the verifications listed above that may require the support of Federalagencies.




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3.6The Exchange has the appropriate privacy protections and capacity to accept, store, associate, and processdocuments received from individual applicants and enrollees electronically, and the ability to accept, image,upload, associate, and process paper documentation received from applicants and enrollees via mail and/or fax.

Completed

Yes No


09/03/2015

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3.6aThe Exchange has the appropriate privacy protections and capacity to accept, store, associate, and processdocuments received from applicants and enrollees electronically.

Completed

Yes No


09/03/2015

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3.6bThe Exchange has the appropriate privacy protections and capacity to accept, image, upload, associate, andprocess paper documentation received from applicants and enrollees via mail and/or fax.

Completed

Yes No


09/03/2015

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3.7The Exchange has the capacity to determine individual eligibility for enrollment in a QHP through the Exchangeand for employee and employer participation in the SHOP. In addition, the Exchange has the capacity to assessor determine eligibility for Medicaid and CHIP based on Modified Adjusted Gross Income (MAGI).

Completed

Yes No


09/03/2015

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3.7aThe Exchange has the capacity to determine individual eligibility for enrollment in a QHP through the Exchange.

Completed

Yes No


09/03/2015

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3.7b1The Exchange has the capacity to determine eligibility for Medicaid and CHIP based on MAGI. OR

Not Applicable

Completed

Yes No


09/03/2015

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3.7b2The Exchange has the capacity to assess eligibility for Medicaid and CHIP based on MAGI.

Not Applicable

Completed

Yes No

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3.7cThe Exchange has the capacity to determine eligibility for employee and employer participation in SHOP.

Completed

Yes No


09/03/2015

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3.7dThe Exchange has the capacity to accept and process applications that have been transferred from otheragencies administering Insurance Affordability Program(s).

Completed

Yes No


09/03/2015

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3.8The Exchange has the capacity to determine eligibility for Advance Payments of the Premium Tax Credit (APTC)and Cost Sharing Reductions (CSR), including calculating maximum APTC, independently or through the use of aFederally-managed service.

Completed

Yes No


09/03/2015


If the Exchange is using Federally-managed Services: Provide a description of the end-to-end process, including activities conducted by the Exchange andintegration points with the Federally-managed service.




Test Documents


Not Applicable




Not Applicable



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3.9The Exchange has the capacity to independently send notices, as necessary, to applicants and employerspursuant to 45 CFR 155, subpart D that are in plain language, address the appropriate audience, and meetcontent requirements.

Completed

Yes No


09/03/2015

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3.10The Exchange has the capacity to accept applications and updates, conduct verifications, and determineeligibility for individual responsibility requirement and payment exemptions independently or through the use of Federally-managed services.

Completed

Yes No


09/03/2015


If the Exchange is using Federally-managed Services: Provide brief descriptionof the end-to-end process, including activities conducted by the Exchange andintegration points with the Federally-managed service.

Brief Description




Test Documents


Not Applicable




Not Applicable




Not Applicable

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3.11The Exchange has the capacity to support the eligibility appeals process and to implement appeals decisions, asappropriate, for individuals, employers, and employees.

Completed

Yes No


09/03/2015

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3.12The Exchange and SHOP have the capacity to process QHP selections and terminations in accordance with 45CFR 155.400 and 155.430, compute actual APTC, and report and reconcile QHP selections, terminations, and APTC/advance CSR information in coordination with issuers and CMS. This includes exchanging relevantinformation with issuers and CMS using electronic enrollment transaction standards.

Completed

Yes No


09/03/2015

Test Documents










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3.12aThe Exchange has the capacity to process QHP selections and terminations using electronic enrollmenttransaction standards in coordination with issuers and CMS.

Completed

Yes No


09/03/2015

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3.12bThe Exchange has the capacity to compute actual APTC.

Completed

Yes No


09/03/2015

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3.12cThe Exchange has the capacity to report and reconcile QHP selections, terminations, and APTC/advance CSR information in coordination with issuers and CMS.

Completed

Yes No


09/03/2015

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3.12dThe SHOP has the capacity to process QHP selections and terminations, including reporting and reconcilingselection and termination information.

Completed

Yes No


09/03/2015

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3.13The Exchange has the capacity to electronically report results of eligibility and exemption assessments anddeterminations, and provide associated information to HHS, IRS, and other agencies administering Insurance Affordability Programs, as applicable. This includes information necessary to support administration of the APTCand CSR as well as to support the employer responsibility provisions of the Affordable Care Act.

Completed

Yes No


09/03/2015

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3.14In accordance with section 155.345(i) of the Exchange Final Rule, the Exchange must follow proceduresestablished in accordance with 45 CFR 152.45 related to the Pre-Existing Condition Insurance Plan (PCIP)transition.

Completed

Yes No

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4.0 - Plan Management (100% Completed)

4.1The Exchange has the appropriate authority to perform the certification of QHPs and to oversee QHP issuersconsistent with 45 CFR 155.1010(a).

Completed

Yes No


07/10/2015


Citation of the Stateâs applicable statutory and/or regulatory authority(ies).



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4.2The Exchange has a process in place to certify QHPs pursuant to 45 CFR 155.1000(c) and according to QHPcertification requirements contained in 45 CFR 156.

Completed

Yes No


07/31/2015


Brief description of how the Exchange will ensure that the issuers and healthplans meet each of the QHP certification standards. Include the process thatthe Exchange will use to evaluate issuers and health plans against each of theQHP certification standards, including any differences specific to SHOP.

Brief Description




__AND__ Brief description of entities responsible for QHP certification andbriefly describe the roles and responsibilities of each entity as they relate toeach of the QHP certification standards.

Brief Description




__AND__ Brief description of the integration between the Exchange and theState Department of Insurance.

Brief Description

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4.2aThe Exchange has the capacity to certify QHPs in advance of the annual open enrollment period pursuant to 45CFR 155.1010(a) (1).

Completed

Yes No


08/25/2015

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4.2bThe Exchange has the capacity to ensure QHPs comply with the QHP certification standards contained in 45 CFR 156 including, but not limited to, standards relating to licensure, solvency, service area, network adequacy,essential community providers, marketing and discriminatory benefit design, accreditation, and consideration of rate increases.

Completed

Yes No

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4.2cThe Exchange has the capacity to collect, analyze, and if required, submit to the Federal government for reviewQHPs' plan variations for cost-sharing reductions, advance payment estimates for such reductions, and anysupporting documentation needed to ensure compliance with applicable regulations and accuracy of thecost-sharing reduction advance payments.

Completed

Yes No

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4.2dThe Exchange has the capacity to ensure QHPs meet actuarial value and essential health benefit standards inaccordance with applicable regulations and guidance.

Completed

Yes No

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4.2eThe Exchange has the capacity to ensure QHPs' compliance with market reform rules in accordance withapplicable regulations and guidance.

Completed

Yes No

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4.3The Exchange uses a plan management system(s) or processes that support the collection of QHP issuer andplan data; facilitate the QHP certification process; manage QHP issuers and plans; and integrate with otherExchange business areas, including the Exchange Internet Web site, call center, quality, eligibility andenrollment, and premium processing.

Completed

Yes No


09/03/2015


Brief description of the anticipated number of health plans expected toparticipate in the Exchange.

Brief Description




__AND__ Brief description of the collection method and applicable systems thatwill be used to support the business operations of Plan Management.

Brief Description

PA collects QHP issuer and plan data through SERFF.PA elects to leverage the federal platform forintegration with other Exchange business areas,including the Exchange Internet Web site, callcenter, quality, eligibility and enrollment,...




Test Documents




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4.3aThe Exchange has the capacity to collect and analyze information on plan rates, covered benefits, andcost-sharing requirements pursuant to 45 CFR 155.1020.

Completed

Yes No

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4.3bThe Exchange has the capacity to use plan rate data and rules for purposes such as generating consumer-facingpremiums and determining the second-lowest cost silver plan for premium tax credit calculations.

Completed

Yes No


09/03/2015

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4.4The Exchange has the capacity to ensure QHPs' ongoing compliance with QHP certification requirementspursuant to 45 CFR 155.1010(a)(2), including a process for monitoring QHP performance and collecting,analyzing, and resolving enrollee complaints.

Completed

Yes No


Brief description of approach to ensuring QHP compliance and monitoring of QHP performance, including any integration between Exchange and otherState entities.

Brief DescriptionThe PID would perform compliance and complaintmonitoring on behalf of the Exchange. Regardingcompliance, the PA Insurance Department (PID)conducts market conduct exams on health insuranceissuers in accordance with the NAICâs Ma...




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4.4aThe Exchange has the capacity to ensure QHPs' ongoing compliance with QHP certification requirementspursuant to 45 CFR 155.1010(a) (2) and Exchange operational requirements.

Completed

Yes No

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4.4bThe Exchange has a process to monitor QHP performance and to collect, analyze, and resolve enrolleecomplaints in conjunction with any applicable State entities (e.g., State Department of Insurance, consumerassistance programs, and ombudsmen).

Completed

Yes No

90


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4.5The Exchange has the capacity to support issuers and provides technical assistance to ensure ongoingcompliance with QHP issuer operational standards.

Completed

Yes No


09/03/2015


Description of issuer technical assistance and support activities to be providedby the Exchange and examples where applicable.




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4.6The Exchange has a process for QHP issuer recertification, decertification, and appeal of decertificationdeterminations pursuant to 45 CFR 155.1075 and 155.1080.

Completed

Yes No


07/31/2015


Brief description of the process for transitioning enrollees to new QHPs in theevent of a QHP decertification, including any differences specific to SHOP.

Brief Description




__AND__ Brief description of general approach for decertification,recertification, and appeals of decertification.

Brief Description




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4.6aThe Exchange has a process for recertification of QHP issuers and QHPs including the annual receipt and reviewof QHP rate, benefit, and cost sharing information pursuant to 45 CFR 155.1020(c).

Completed

Yes No


07/31/2015

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4.6bThe Exchange has a process for decertification of QHPs and QHP issuers and a process for transitioningenrollees into new QHPs pursuant to 45 CFR 155.1080.

Completed

Yes No


07/31/2015

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4.6cThe Exchange has a process for the QHP issuer appeal of a decertification of a QHP pursuant to 45 CFR 155.1080 and any necessary appeal of QHP certification determinations consistent with any applicable Statelaws or regulations.

Completed

Yes No


07/31/2015

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4.7The Exchange has set a timeline for QHP issuer accreditation in accordance with 45 CFR 155.1045. TheExchange also has systems and procedures in place to ensure QHP issuers meet accreditation requirements (per45 CFR 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.

Completed

Yes No


07/31/2015

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4.8The Exchange has systems and procedures in place to ensure that QHP issuers meet the minimum certificationrequirements pertaining to quality reporting and provide relevant information to the Exchange and HHSpursuant to Affordable Care Act 1311(c)(1), 1322(e)(3), and as specified in rulemaking.

Completed

Yes No


07/31/2015

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6.0 - SHOP (100% Completed)

6.1The SHOP is compliant with regulatory requirements pursuant to 45 CFR 155 Subpart H.

Completed

Yes No


09/03/2015


Brief description of how the size of a small business is determined in theExchange and whether the small group market includes employers with 51 to100 employees in 2014 and 2015.

Brief Description

PA opts to keep the size of a small employer at 1-50for as long as federally permitted. PA uses thefederal FTE method to count employees.




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6.1aThe SHOP has capacity to allow a qualified employer to select a level of coverage as described in the AffordableCare Act 1302(d) (1), in which all QHPs within that level are made available to the qualified employees of theemployer.

Completed

Yes No


09/03/2015

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6.1bThe SHOP has capacity to ensure that all QHP issuers make rate changes at a uniform time that is eitherquarterly, monthly, or annually, and has the capacity to prohibit all QHP issuers from varying rates for aqualified employer during the employer's plan year.

Completed

Yes No

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6.1cThe SHOP has capacity to offer small employers only QHPs that meet the requirements for the State's smallgroup market.

Completed

Yes No


09/03/2015

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6.1dIf the SHOP decides to implement minimum participation requirements, the SHOP has capacity to authorizeuniform group participation rules for the offering of health insurance coverage in the SHOP.

Not Applicable

Completed

Yes No

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6.1eThe SHOP has established a premium calculator, as described in 45 CFR 155.205(b) (6), to facilitate thecomparison of available QHPs after the application of any applicable employer contribution in lieu of anyadvance payment of the premium tax credit and any cost-sharing reductions.

Completed

Yes No


09/03/2015

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6.2The Exchange has the capacity for SHOP premium aggregation pursuant to 45 CFR 155.705.

Completed

Yes No


09/03/2015

Test Documents










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6.2aThe Exchange has the systems in place for billing employers, receiving employer and employee contributionstoward premiums, and making aggregated premium payments to issuers.

Completed

Yes No


09/03/2015

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6.2bThe Exchange has a process for managing non-payment or late premiums; including how and when notices aresent to employers.

Completed

Yes No


09/03/2015

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6.3The SHOP Exchange has the capacity to electronically report information to the IRS for tax administrationpurposes.

Completed

Yes No


09/03/2015

Test Documents










Work Plan


SizeDateUploaded

PA SSBM Application

Summary


Summary05-22.pdf

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7.0 - Organization and Human Resources (100% Completed)

7.1The Exchange has an appropriate organizational structure and staffing resources to perform Exchange activities.

Completed

Yes No


07/17/2015


Organizational chart

Brief Description




__AND__ Brief description of the hiring strategy that addresses competencies,roles, and responsibilities needed to perform key Exchange activities.




Work Plan


SizeDateUploaded



617.72Kb

06/01/2015


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7.1aThe Exchange has an organizational structure that includes leadership/key staff and encompasses key Exchangeactivities.

Completed

Yes No


07/17/2015

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06/01/2015

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7.1bThe Exchange has a hiring strategy that addresses competencies, roles, and responsibilities needed to performkey Exchange activities.

Completed

Yes No


07/17/2015

Work Plan


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06/01/2015

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8.0 - Finance and Accounting (100% Completed)

8.1The Exchange has a long-term operational cost, budget, and management plan.

Completed

Yes No


07/24/2015


Brief description of the methods the Exchange will use to generate revenue andhow the Exchange will address any financial deficits.

Brief Description




__AND__ Model budget entailing expected operating costs, revenues, andexpenditures.




Work Plan


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617.72Kb

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8.1aThe Exchange has a long-term operational budget and management plan, monitors its finances, and is able totrack its costs and revenues.

Completed

Yes No


07/24/2015

Work Plan


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617.72Kb

06/01/2015

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8.1bThe Exchange has defined methods for generating revenue (e.g., user fees) pursuant to Affordable Care Act1311(d) (5) (A), and has the appropriate legal authority.

Completed

Yes No


07/10/2015

Work Plan


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617.72Kb

06/01/2015



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9.0 - Technology (100% Completed)

9.1The Exchange technology and system functionality complies with relevant HHS information technology (IT)guidance.

Completed

Yes No


09/09/2015


Brief description of any areas of significant variation between Exchangetechnology and system functionality and HHS IT guidance.

Brief Description

PA elects to use the federal technology platform.




Work Plan


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9.2The Exchange has the adequate technology infrastructure and bandwidth required to support all of the Exchangeactivities.

Completed

Yes No


09/03/2015

Work Plan


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9.3The Exchange effectively implements IV&V, quality management, and test procedures for Exchange-developmentactivities and demonstrates it has achieved HHS-defined essential functionality for each required activity.

Completed

Yes No


09/03/2015


Brief description of the front-end system engineering work including IT, qualityassurance processes and IV&V services used to validate requirements, businessprocesses and development of the Exchange.

Brief Description

PA elects to use the federal technology platform.




Work Plan


SizeDateUploaded



05-22.pdf

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10.0 - Privacy and Security (100% Completed)

10.1The Exchange has established and implemented written policies and procedures regarding the Privacy andSecurity standards set forth in 45 CFR 155.260(a) â (g).

Completed

Yes No


09/03/2015