BULLETIN 2013-03 (REVISED AND REISSUED): Enforcement Authority Re: ACA and MHPAEA
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Describes LDI enforcement authority and procedures for reviewing issuer compliance with the ACA and MHPAEA, and sets filing and plan submission requirements for issuers offering plans in Louisiana, including QHPs.
No material clinical or coverage changes in this revision.
Filing, Submission, and Coverage Criteria
inv-01: Filing & Plan Submission Criteria
Filing and plan submission requirements for issuers delivering or issuing plans in Louisiana:
inv-02: Filing and disclosure criteria
Filing and disclosure requirements
Product Codes and Service Disclosures
| NG-CAT PLAN | Non-grandfathered catastrophic plan product code |
| NG-CONT ONLY | Non-grandfathered contraceptive-only product code |
| NG-SA.P.DENTAL | Non-grandfathered stand-alone pediatric dental product code |
| NG.HMO-IND | Non-grandfathered HMO - individual |
| Issuers must provide a narrative description or listing with form/section/page references describing how the habilitative services Essential Health Benefits category is met. |
Required Actions, Notices, and Submissions
Notice and Referral for Non-Compliance
If LDI determines a delivered or issued plan/policy is not in compliance with ACA or MHPAEA, it will issue a notice of non‑compliance and request that the issuer amend and re-file the policy forms; if the issuer fails to amend, LDI will refer the noncompliant form(s) to CMS for determination of formal enforcement action.
- LDI will review revised forms after the issuer re-files amended policy forms.
- If issuer fails to amend, LDI will forward the matter and noncompliant form(s) to CMS for enforcement.
Complaint Handling and Referral
LDI will respond to consumer inquiries and complaints related to the ACA and MHPAEA and request that issuers address and resolve complaints; if an issuer refuses corrective action or a pattern of noncompliance is discovered, LDI will forward the inquiry/complaint to CMS and may pursue further investigation or a targeted market conduct examination.
- If issuer refuses to take corrective action, LDI will forward a copy of the inquiry/complaint to CMS for possible enforcement.
- If an investigation reveals a pattern or practice of noncompliance, LDI will consult with CMS and may perform a targeted market conduct examination; CMS may independently initiate examinations per 45 C.F.R. §150.313.
Schedule of Benefits submission
Issuers must submit a plan-specific Schedule of Benefits for each plan offered on or off the Exchange/Marketplace to LDI using the SERFF Plan Management functionality.
- Submission is required for every plan, whether offered on-Exchange or off-Exchange.
- Use the SERFF Plan Management functionality to file the plan-specific Schedule of Benefits.
Summary of Benefits Coverage submission
A Summary of Benefits Coverage (SBC) must be submitted to LDI for each plan filed using the SERFF Plan Management functionality, whether the plan is offered on or off the Exchange/Marketplace.
- SBC submission is required for every plan filed via SERFF Plan Management.
Definitions and Enforcement Collaboration
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