Federal Health Insurance Products and Plans: Definitions and Examples, Exams of Management of Health Service

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Federal Definitions for Health Insurance Products and Plans

CMS Webinar to States

and Issuers

What is a Product?

A product is a discrete package of health insurance coverage benefits that are offered using a particular

product network type (such as health maintenance organization, preferred provider organization, exclusive

provider organization, point of service, or indemnity) within a service area. In the case of a product that has

been modified, transferred, or replaced, the resulting new product will be considered to be the same as the

modified, transferred, or replaced product if the changes to the modified, transferred, or replaced product

meet the standards of 45 CFR § 146.152(f), § 147.106(e), or § 148.122(g) (relating to uniform modification of

coverage), as applicable.

Any set of plans that share a network type and a set of benefits is a product.

Limitations on benefit coverage, such as limits based on the frequency of treatment, number of visits, days of

coverage, or other similar limits on the amount, scope or duration of treatment, which specify the scope of

benefits covered rather than the health care provider payment portion owed by the consumer, are considered

to be features of a product’s “discrete package of health insurance coverage benefits” rather than a plan’s

“cost-sharing structure”.

The definitions of product and plan were updated in the Final Rule Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2018; Amendments to Special Enrollment Periods and the Consumer Operated and Oriented Plan Program published December 22, 2016. See 45 CFR § 144.103.

Examples of Products

If the Issuer wanted to change Product A and provide the same benefits with an EPO network, that would result in a NEW product – Product D, which should have unique product IDs in HIOS.

If the Issuer wanted to offer Product B on the marketplace and submitted its plans for QHP Certification, it would NOT be a different product and Product IDs in HIOS would remain the same.

. Product A Product D Product B

(Non-QHP)

Product B

(QHP)

Benefits Covered

Same benefit package as State EHB Benchmark – no pediatric dental (QHP)

Same benefit package as State EHB Benchmark – no pediatric dental (QHP)

Same benefit package as State EHB Benchmark – with Pediatric Dental (Non- QHP)

Same benefit package as State EHB Benchmark – with Pediatric Dental (QHP)

Network Type

PPO EPO PPO PPO

Plans under Product

Plan A1 – Bronze Plan A2 – Silver Plan A3 – Gold

Plan D1 – Bronze Plan D2 – Silver Plan D3 – Gold

Plan B1 – Silver Plan B2 – Gold

Plan B1 – Silver Plan B2 – Gold

Plan Finder – Product and Plan

• • • • • • •

A product is a discrete package of health insurance coverage benefits that are offered using a particular

product network type (such as health maintenance organization, preferred provider organization, exclusive

provider organization, point of service, or indemnity) within a service area. In the case of a product that has

been modified, transferred, or replaced, the resulting new product will be considered to be the same as the

modified, transferred, or replaced product if the changes to the modified, transferred, or replaced product

meet the standards of 45 CFR § 146.152(f), § 147.106(e), or § 148.122(g) (relating to uniform modification of

coverage), as applicable.

For purposes of the Federal Health Insurance Oversight System (HIOS), the identifier for a health insurance

product sold in a State is the Product ID, and it is generated upon submission to HIOS. Plans, with respect to

a product, are the pairing of the health insurance coverage benefits under the product with a particular cost

sharing structure, provider network, and service area that are offered to consumer.

Cost-sharing and benefit information is entered into the Rates and Benefits Information System (RBIS), through the HIOS system RBIS information will appear on the Plan Finder for consumers to review and compare Each plan in RBIS must match a product record in HIOS Issuer ID + Product ID combine with information at the plan level to create a unique identifier – the Standard Component ID

The definitions of product and plan were updated in the Final Rule Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2018; Amendments to Special Enrollment Periods and the Consumer Operated and Oriented Plan Program published December 22, 2016. See 45 CFR § 144.103.

Is it a Product or a Plan?

Gold, Silver, and Bronze metal levels are determined by cost share differences only

Benefits covered are the same

Network type is the same

These are not different products, but rather different plans under the same product.

What is a Plan?

A plan is the pairing of the health insurance coverage benefits under a product and a particular cost-sharing structure, provider network, and service area

The product comprises all plans offered within the product

The combination of all service areas of the plans offered within a product constitutes the total service area of the product

Plans within a product can vary based on cost sharing structure, provider network, and service area

Example of Service Area Determination

. Product A – service area A,C,D,E,F,G,L,X,Z

Product B – service area A, B, C, D, K, L, N, Q

Product C – service area A - Z

Benefits Covered Same benefit package as State EHB Benchmark – no pediatric dental (QHP)

Same benefit package as State EHB Benchmark – pediatric dental (non- QHP)

Same benefit package as State EHB Benchmark – no pediatric dental (QHP)

Network Type PPO PPO HMO

Plans Plan A1 – $2,000/$3, indiv/fam ded; plan pays 60; service areas: A, D, E

Plan A2 – $1,500/$2, indiv/fam ded; pays 70%; service areas C, F, G, L, X,

Plan A3 – $1,000/$1, indiv/fam ded; pays 80%; Service areas A, C, X, Z

Plan B1 – $1,500/$2, indiv/fam ded; pays 70; service areas: A, B, C, D

Plan B2 – $1,000/$1, indiv/fam ded; pays 80%; service areas A, B, K, L, N, Q

Plan A1 – $2,500/$4, indiv/fam ded; pays 65%; service areas: A - L

Plan A2 – $1,500/$2, indiv/fam ded; pays 75% Plan A3 – Gold: service areas A - N

Plan A3 – $500/$1, indiv/fam ded; pays 85%; Service areas; A – Z

Who to Ask in CCIIO

Questions related to HIOS IDs are to be directed to:

Brian James, Division Director, Non-Exchange Insurance Issuer Data Collection email: Brian.James@cms.hhs.gov work phone: 301-492-

Questions related to Uniform Rate Review Template and Actuarial Memorandum submissions are to be directed to:

Brent Plemons, Deputy Director, Rate Review Division email: Brent.Plemons@cms.hhs.gov work phone: 301-492-

Questions related to Direct Enforcement Form Filing submissions are to be directed to:

Mary Nugent, Deputy Director, Compliance and Enforcement Division email: Mary.Nugent@cms.hhs.gov work phone: 410-786-