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Insurance FAQs

Issuer-specific

  • The OPM will negotiate terms of coverage with each multi-state plan, including medical-loss ratio, profit margin and premiums, and may prohibit MSPs that fail to meet these terms and conditions from participating in the state exchanges.
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  • The insurers selected to be in the multi-state plan must be licensed in each State and are subject to all requirements of state law, except those that would prevent the application of provisions of the Act. OPM may set additional requirements for participating insurers in consultation with HHS.
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  • In order to be approved to offer one or more Multi-State Plan options, an insurer, among other things, must—
    • meet requirements for qualified health plans under the Affordable Care Act;
    • offer a package of “essential health benefits”; and
    • determine premiums using the rating rules under the Affordable Care Act except that if the state has more protective age rating requirements, defer to the state age rating rules.
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  • Although OPM reviews and approves MSP applications, OPM expects MSP insurers to comply with State law requirements relating to the review of policy forms and benefits.  OPM works closely with each State in reviewing MSP applications and consults with each State as appropriate to ensure that the MSP options are not disruptive to markets.
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  • As a general rule, Multi-State Plan (MSP) insurers have to comply with applicable State laws.  The Affordable Care Act reserves the possibility that certain exceptions to State law may become necessary for appropriate OPM oversight of the program.  
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  • The Directory of Headquarters Level Agency Benefit Officers can be found at: http://apps.opm.gov/abo/
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  • An MSP Program issuer must ensure that the provider network of each of its MSP options, as available to all enrollees, meets the following standards: • is sufficient in number and types of providers to ensure that all services will be accessible to enrollees without unreasonable delay; • is consistent with the network adequacy provisions of section 2702(c) of the Public Health Service Act; and • includes essential community providers in compliance with 45 C.F.R. § 156.235. In addition, an MSP Program issuer must make its provider directory for each MSP available to the Exchange for publication online pursuant to guidance from the Exchange and to potential enrollees in hard copy upon request. In the provider directory, an MSP Program issuer must identify providers that are not accepting new patients.
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