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Home > Insurance Division > Health Insurance Programs > Plan Management
Qualified Health Plan Instructions for Plan Year 2022

The New Jersey Department of Banking and Insurance (Department) operates New Jersey’s official health insurance Marketplace, or State Based Exchange (SBE), Get Covered New Jersey.  The Department is performing all plan management functions for Plan Year 2022 and will contract with carriers that intend to offer certified Qualified Health Plans (QHPs) through Get Covered New Jersey.

Note:  There are no separate filing fees.

General Information and Resources

Only carriers (insurance companies, service corporations, and health maintenance organizations) licensed or authorized to offer a health insurance/coverage business in New Jersey may offer a QHP or Stand-alone Dental Plan (SADP) to individuals or small employers for delivery in New Jersey, whether through Get Covered New Jersey or outside of it.


New Carriers, and Carriers seeking to amend an existing Authorization. 
A carrier that is not admitted in New Jersey, or admitted but not authorized, to offer health benefits plans, may apply for admission and/or authorization while also applying to offer QHPs and SADPs; required regulatory reviews will occur parallel to one another when necessary.  This is also the case for carriers authorized to operate in a limited service area that want to expand (or shrink) it, or carriers that want to establish a new network, etc.  Such carriers are cautioned, however, that there are no guarantees how long the various review processes may take, and carriers should not assume all required components will be completed in a timeframe adequate to permit the offer of plans during the designated open enrollment period for the immediately upcoming plan year.  Carriers should note:

  • If a carrier seeking to offer QHPs or SADPs through Get Covered New Jersey does not obtain all required approvals in a timely manner, the carrier will not be permitted to participate in Get Covered New Jersey, because, to participate in Get Covered New Jersey:
    • The carrier must be able to participate fully in the open enrollment period immediately preceding the upcoming calendar year; and
    • The carrier must be able to effectuate coverage as of January 1 of the calendar year immediately following the beginning of the open enrollment period; and
    • The carrier must commit to offering plans through Get Covered New Jersey for a full calendar year.

  • A carrier seeking to offer a QHP to small employers solely outside of Get Covered New Jersey is permitted to begin offering plans at any time during a calendar year. However, when a carrier is unable to offer its QHPs during the small employer annual open enrollment period (November 15 through December 15) designated for the calendar year in which the carrier wants to offer its QHPs, and the carrier elects to start offering its QHPs during that calendar year, the carrier must offer its QHPs on a continuously guaranteed issue basis through the remainder of the  calendar year.  (Participation and contribution requirements must be waived.)


Terminology. 
For purposes of these instructions and related information:

  • QHP is being used to refer to health benefits plans providing medical services and supplies (with or without a defined set of pediatric dental services embedded in the health benefits plan).  All standard health benefits plans available in the individual and small employer markets (see below) are QHPs.  To become certified for offer through Get Covered New Jersey, both the carrier and the QHP must meet certain requirements, and the carrier must enter into a contract with the Department.

  • SADP is being used to refer to dental only plans that include the defined set of pediatric dental services and that carriers intend to offer to individuals and/or employees of small employers that have enrolled in QHPs that do not embed coverage of pediatric dental services.  To become certified for offer through Get Covered New Jersey, both the carrier and the SADP must meet certain requirements, and the carrier must enter into a contract with the Department to participate in Get Covered New Jersey.


Standard Health Benefits Plans, the Benchmark Plan, Qualified Health Plans and Stand-Alone Dental Plans

New Jersey has standard health benefits plans for its individual and small employer markets, and carriers may offer only standard health benefits plans to individuals and small employers.  All of New Jersey’s standard health benefits plans are consistent with New Jersey’s Benchmark Plan required by the federal Affordable Care Act (ACA), including an option for embedded coverage of a defined set of pediatric dental services.  However, carriers may offer the defined set of pediatric dental services through SADPs as well.  CCIIO provides a link to New Jersey’s Benchmark Plan, and provides separate information about the defined set of pediatric dental benefits via https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html.  (Scroll to access information about each state individually.)


Locating QHP Information:
Carriers that wish to offer a QHP, with or without pediatric dental services embedded in the plan, must issue the standard health benefits plans set forth in the Appendix Exhibits of N.J.A.C. 11:20 and N.J.A.C. 11:21, and as posted at:

The standard health benefits plans forms include variable text for the pediatric dental services.  Carriers also should refer to the “BMP Summary” at https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html to obtain more specific information about the Prescription Drug EHB-Benchmark Plan Benefits by Category and Class.


Locating SADP Information: 
Because the standard health benefits plans contain the required benefits and language to comply with New Jersey’s selected benchmark pediatric dental coverage, the Department recommends that carriers wishing to offer an SADP with the ACA-compliant pediatric dental coverage look to the relevant variable text in the standard health benefits plans at:

Alternatively, carriers may refer to https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html, paying particular attention to New Jersey’s BMP Summary and NJ-CHIP files.   


General offer requirement: 
Carriers that offer a QHP through Get Covered New Jersey must also offer the same standard health benefits plan outside of Get Covered New Jersey.  Carriers may offer a standard health benefits plan solely outside of Get Covered New Jersey, but the standard health benefits plan still must meet the requirements applicable to a QHP, with a few exceptions.  This is true whether coverage is being offered to individuals or small employers.

Similarly, carriers that offer an SADP through Get Covered New Jersey must also offer the same SADP outside of Get Covered New Jersey; however, carriers may offer an SADP solely outside of Get Covered New Jersey.  Carriers offering SADPs must structure their plans so that a child may be covered by the SADP without regard whether a parent or guardian is also covered under the SADP.  (Note that if multiple children in the same family need coverage, each child would enroll separately.  To cover multiple children under the same policy, a parent or guardian must be covered.)  This is true whether coverage is being offered to individuals or small employers, and whether coverage is being offered through Get Covered New Jersey or not. 

 
The Basics of Submission and Market Participation

Who must submit information: All carriers that intend to offer a standard health benefits plan in the individual or small employer market during Plan Year 2022 must submit plan management information, whether or not the standard health benefits plan will be offered through Get Covered New Jersey.  Similarly, carriers that intend to offer an SADP in the individual or small employer market during Plan Year 2022 must submit plan management information, whether the SADP will be offered through Get Covered New Jersey, or not.  Carriers offering standard health benefits plans solely outside of Get Covered New Jersey must submit most, but not all, of the information required to be submitted by carriers that are seeking certified QHP status for plans to be offered through Get Covered New Jersey. All carriers offering SADPs must submit specified documentation, regardless of whether the plan will be offered through Get Covered New Jersey or SHOP.


What must be submitted: 
Except as indicated otherwise, carriers will complete and submit the templates developed by the Center for Consumer Information and Insurance Oversight (CCIIO) for the Federally Facilitated Exchange for Plan Year 2022, as well as supporting documentation, using the instructions prepared by CCIIO for its templates and supporting documentation.  Carriers should see https://www.qhpcertification.cms.gov/s/QHP.  There are additional documents/submissions required for QHPs and SADPs.  In addition, there are special instructions for use of several of the CCIIO templates.  More details are provided below, and a chart of the documentation is provided for easier reference.


When must items be submitted:
   The following dates apply:

Submission Deadline Overview Chart Deadline System
2021 QHP Enrollee survey data May 24, 2021 Survey Vendor
2021 QRS Clinical Data June 15, 2021 NCQA IDSS
Initial Binder components deadline (not including the Rates Table Template, rate filing, Transparency in Coverage data) June 11, 2021 SERFF
Transparency in Coverage data (NJ-initial) June 16, 2021 SERFF
Machine-readable index URL submission deadline June 16, 2021 SERFF
Rates Table Templates July 21, 2021 SERFF
Transparency in Coverage data (for CMS initial) Aug. 18, 2021 SERFF
Issuer URL Template (final) Aug. 18, 2021* SERFF
New plan year machine-readable submission deadline August 18, 2021 SERFF
Prescription drug template ** SERFF
*Marketing URLs must be live and active no later than August 22, 2021.
** Quarterly filing due dates: January 15, 2022; April 15, 2022; July 15, 2022; October 15, 2022


Where/How must carriers submit the information. 
Carriers must submit all documents through SERFF, except as noted.  Most documents must be submitted through the Plan Binder section of SERFF.  A few documents must be submitted through SERFF either as part of the process for rate filings (applicable to all QHPs and SADPs), or form filings (applicable only to SADPs).  However, carriers must associate documents from the rate filings and/or the form filings with the relevant plan binders using the Associate Schedule Tab of the Plan Binder section of SERFF.

Carriers must submit QHP Enrollee Survey data to the carrier-selected HHS-approved survey vendor, which will submit the data to CMS.  Carriers’ validated QRS clinical measure data, with attestation, must be submitted to the NCQA’s Interactive Data Submission System (IDSS).  For more information, see guidance and resources at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/ACA-MQI/Consumer-Experience-Surveys/Surveys-page.    

Get Covered New Jersey Offerings: For carriers seeking to offer QHPs or SADPs through Get Covered New Jersey, additional guidance will outline the operational timelines associated with reviewing and verifying accuracy of the 2022 plan data in Get Covered New Jersey plan compare system. Carriers are required and responsible for validating that the data submitted for each QHP or SADP is displaying as intended on the consumer-facing plan selection interface. This will occur in the July and August timeframe. After final reviews of data and verification that all standards are met, carriers and Get Covered New Jersey will formalize QHP and SADP offerings through an annual Certification Agreement signed by both entities in September.

 
Documentation (the Application)

The Documents to be Submitted chart identifies which documents must be submitted for which types of plans.  A majority of the templates and forms to be used are available through CCIIO, but some additional instructions are provided below. 


Cover Letter to Binder
Carriers must submit a cover letter for each binder submitted.  Carriers should place the Cover Letter on the Supporting Documents tab of the Plan Management domain in SERFF.  The cover letter must include:

  • the carrier’s name and HIOS ID
  • the SERFF tracking number for the binder
  • the names and email addresses for two contact people who are familiar with the filing and able to respond to questions
  • a table with the following:
    • Product and plan name(s)
    • HIOS ID for each plan (Standard Component ID)
    • Indication of whether the plan will be offered in the individual (IHC) or small employer (SEH) market
    • For QHPs, the metal level and the specific AV for each plan if available when submitted
    • For SADPs, the AV for each plan when available
    • Indication of whether the plan will be offered inside/outside of the Marketplace, or outside the Marketplace only


NJ Benefit Summary Table  
Carriers must submit the NJ Benefit Summary Table, with a worksheet completed for each QHP (plan, not product) the carrier wants to offer.  The NJ Benefit Summary Table is available as part of the SERFF Plan Management instructions.  Carriers should place the NJ Benefit Summary Table on the Supporting Documents tab of the Plan Management domain in SERFF.  Carriers do not need to submit this template for SADPs.


Administrative Information, including URLs
Carriers have been required to submit administrative information to CMS though HIOS, and should update that information as necessary to keep it current so long as the carrier is offering QHPs through Get Covered New Jersey, or offering SADPs.  This may include updating URLs using the HIOS Supplemental Submission Module (SSM, part of the QHP Benefits and Service Area Module).  Carriers should update URL information for plans to be offered on the Exchange through the SSM (carriers may be able to generate a prepopulated Issuer URL Template for Plan Year 2022), as appropriate, and append the downloaded file to the Supporting Documents tab of the Plan Management domain in SERFF for each QHP and SADP binder the carrier submits.  Carriers may add information for plans offered solely off the Exchange, or submit a separate URL Template for off-Exchange plans (see: https://www.qhpcertification.cms.gov/s/Administrative).  We request that carriers append the most current URL information on June 11 (which may be for PY2021), and additional updated versions as necessary for PY2022.  Subsequent to transfer by the Department of carrier plan and benefits data to Get Covered New Jersey, a carrier’s intended PY2022 Plan IDs should be recorded in the SSM, and carriers should update information accordingly, submitting a final, completed Issuer URL Template in SERFF (prepopulated by the SSM, if possible) no later than August 18, 2021.  The Department is requesting that all URLs be “live and active” by August 22, 2021.


Accreditation
If the carrier is offering QHPs in New Jersey for three or fewer consecutive years, the carrier may submit a certificate of accreditation, or evidence of a scheduled review with an HHS-recognized accrediting entity (URAC, NCQA, or possibly AAAHC).  If the carrier is offering QHPs for the fourth consecutive year in New Jersey, whether through or outside of Get Covered New Jersey, the carrier must submit a certificate of accreditation by one of the HHS-recognized accrediting entities in one of the following statuses:

  • AAAHC:  Accredited
  • NCQA: Excellent, Commendable, Accredited, or Provisional
  • URAC:  Full, or Conditional

Note that, if a carrier is unable to locate the NCQA certificate, it can use the NCQA ISS to obtain a copy of the survey results, and provide a print of the results screen. 


Transparency in Coverage Template

All carriers submitting plans to be sold through Get Covered New Jersey, as well as SADPs that will be offered only outside of Get Covered New Jersey, must submit the Transparency in Coverage template.  We are requesting that carriers submit an initial Transparency in Coverage template by June 16, 2021.  As suggested by CMS, to avoid overwrite issues, the templates submitted for each binder of each HIOS Issuer ID should be the same; that is, each template submitted should include all plan IDs intended to be offered by the carrier in PY2022.  Note it is not necessary for carriers to include any additional actual or dummy plan data in the template submitted June 16.  Carriers must submit completed Transparency in Coverage templates in SERFF no later than August 18, 2021.  Carriers must include actual carrier level and plan level data for the August submission unless the carriers were not offering plans on the Exchange in 2020, or a specific plan was not offered in PY2020, in which case, dummy data will be necessary, as specified in CMS’ instructions.  We require carriers to submit their final, completed Transparency in Coverage Template no later than August 18, 2021.

Other Documents Specified by CCIIO (Some Special Instructions)
All other required forms and templates are available through CCIIO’s websites.  All can be accessed through https://www.qhpcertification.cms.gov/s/QHP, although carriers will find more information regarding quality reporting at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/ACA-MQI/ACA-MQI-Landing-Page.  Please note:

  • SADP AV.  The federal cost-sharing limits for SADPs are $375 for one child, and $750 for two or more children for Plan Year 2022.  Carriers may offer SADPs without complying with any specific actuarial value; however, carriers must certify the actuarial value of the SADP, including submission of the AV Supporting Documentation and Justification Form.

  • Summary of Benefits & Coverage.  CCIIO released updates to the Summary of Benefits and Coverage forms (SBCs) for Plan Year 2021, as well as to the coverage examples calculator, guide and narratives, and the Uniform Glossary.  Those updates should continue to be used for PY2022.  In general, carriers should use the SBC forms and instructions set forth by CCIIO, and should evaluate whether to use the updated calculator for estimating out-of-pocket costs for the SBC coverage examples.  However: 

    • On the SBC, in the last sentence of the section Your Right to Continue Coverage, carriers should insert www.getcovered.nj.gov instead of www.HealthCare.gov, and should use the following phone number: 833-677-1010.

    • With respect to plans other than SADPs, carriers are reminded that all plans must comply with P.L. 2019, c. 361 (amendments to New Jersey’s contraceptive coverage requirement), and at least one plan must comply with P.L. 2019, c. 472 (amendments limiting cost-sharing for prescription drugs), and these changes may need to be reflected appropriately in the SBC, for example, when providing information in the section If you need drugs to treat your illness or condition, or explaining preventive services.   Careful explanations will be important particularly when/if combined with a High Deductible Health Plan (HDHP), because:

      • Some contraceptive services required to be covered may be outside of the definition of preventive services as recommended by federal law
      • Both P.L. 2019, c. 361 and P.L. 2019, c. 472 limit carriers to the application of the lowest HDHP deductible possible (for PY2022: $1400 for self-only coverage; $2800 for family) with respect to the provision of coverage for prescription drugs and/or contraceptives.

    • In addition, note that P.L. 2019, c. 472 may have an impact on the SBC example for management of diabetes.   
                     
  • Business Rules. Carriers offering QHPs must not select “sponsored dependents,”  “collateral dependents,” or “other relative” as a coverage category on the Business Rules/Rating Business Rules template because the terms, as used by CCIIO, are inconsistent with the definition of dependent in the standard health benefits plans.  In addition, although the standard individual health benefits plans would allow grandchildren, siblings, nephews, and nieces as eligible dependents, it is conditioned upon such individuals being in the same household and dependent upon the primary insured person.  While CCIIO’s form would allow for a selection of coverage for these classes of people when not in the household, carriers should not make that selection.  Also, an ex-spouse is never eligible for coverage under a primary insured’s individual health benefits plan.

  • QHP Enrollee Survey Data and QRS Clinical Data.  Carriers should follow the requirements set forth at CCIIO’s QHP Certification website (https://www.qhpcertification.cms.gov/s/Quality Rating), and Marketplace Quality Initiatives website (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/ACA-MQI/ACA-MQI-Landing-Page).

  • Plan ID Crosswalk.  The requirement to submit a Plan ID crosswalk applies to carriers offering QHPs as well as to carriers offering SADPs when offering through Get Covered New Jersey.  Carriers must crosswalk all prior year Plan IDs to a Plan Year 2022 Plan ID taking into consideration the hierarchy set forth at 45 C.F.R. 155.335 to help expedite the auto-reenrollment process. 

 

Additional Requirements     

Rate Filings
Carriers must submit rate filings. Additional instructions are provided on the Department of Banking and Insurance website and in SERFF, separate and apart from these instructions.  The CCIIO-generated URRT must be included as part of the rate filing for QHPs.  All three parts of the rate filing must be associated with the Plan Management binder to which the rate filing applies, using the Associate Schedule tab of the Plan Management domain of SERFF.

Form Filings
Carriers offering SADPs must file forms with the Department, or submit a letter indicating that a previously approved form remains in use without change in SERFF (but not the SERFF Plan Management domain).  Carriers must associate both forms and letters with the SADP binders to which the form/letter applies, using the Associate Schedule tab of the Plan Management domain of SERFF.   

QHP Certification Agreement
Carriers intending to offer a QHP through Get Covered New Jersey, or an SADP, must sign the QHP Certification form agreeing to adhere to operational and technical standards, privacy requirements, and security protocols outlined by Get Covered New Jersey. The certification agreement will formalize the offering of a carrier’s QHPs or SADPs through Get Covered New Jersey for the plan year.  This documentation can be obtained from and returned to Get Covered New Jersey directly.

Withdrawal of a plan.  Although a carrier may not remove a plan from its templates, carriers may seek to withdraw a plan, or change its SBE-status using the Plan Withdrawal Notification Form, submitted in the SERFF Plan Management domain.  (Carriers are reminded that withdrawal of a plan is not the equivalent of a withdrawal from the market and that specific market withdrawal rules apply to such actions.)

 
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