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  • 20 Apr 2023 10:06 AM | Destiny Ruth (Administrator)


    This memorandum details the filing timelines for issuers offering:

    • individual or small group1non-grandfathered health insurance coverage2; or
    • coverage of pediatric dental services under Exchange-certified Stand-Alone Dental Plans (SADPs).

    It applies to coverage with plan or policy years beginning in calendar year 2024. Hereafter, these policies are referred to as 2024 Plans and 2024 SADPs, respectively.


    South Carolina has a Federally Facilitated Marketplace (FFM). However, this Department retains responsibility for the review and approval of forms and rates for 2024 Plans and 2024 SADPs sold on and off the FFM.

    The Center for Consumer Information and Insurance Oversight (CCIIO) sets QHP application and single risk pool rate submission timelines annually, which are summarized in the Key Dates for Calendar Year 2023: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; and Risk Adjustment (posted by CMS on March 28, 2023).

    These federally imposed deadlines are the basis for the filing timeline summarized in this Memorandum. We are requesting that issuers submit filings for 2024 Plans and 2024 SADPs by the following dates:

    Health Insurance Issuers Seeking QHP Certification (excluding SADPs)

    QHP Application Deadline:                                                June 14, 2023

    Submit Rate/ Form Filing in SERFF by:                               June 9, 2023

    Submit Binder in SERFF Plan Management by:                  June 9, 2023

    Submit Rate Filing Justification in URR Module5by:            June 9, 2023     
    SERFF/ URR5System Dispositions Deadline:                August 16, 2023
    State QHP Certification Recommendations Due:     September 20, 2023

    Dental Issuers Seeking SADP Certification (including SADPs that will be offered strictly outside of the FFM and/or FF-SHOP)
    QHP Application Deadline:                                                 June 14, 2023
    Submit Rate/ Form Filing in SERFF by:                                June 9, 2023
    Submit Binder in SERFF Plan Management by:                   June 9, 2023
    SERFF Dispositions Deadline:                                         August 16, 2023
    State QHP Certification Recommendations Due:      September 20, 2023

    Health Insurance Issuers Writing Solely Outside of the FFM
    Submit Rate/ Form Filing in SERFF by:                                  July 7, 2023
    Submit Binder in SERFF Plan Management by:                     July 7, 2023
    Submit Rate Filing Justification in URR Module by:                July 7, 2023
    SERFF/ URR5System Dispositions Deadline:                October 16, 2023

    Open Enrollment for 2024 Plans begins:                       November 1, 2023


    Our continued goal is to provide issuers with the maximum amount of time possible to develop their filings to get better quality, more complete submissions at the beginning of the process.

    With that in mind, we ask that issuers be mindful of the following items relative to the upcoming filing period:

    • Filings cannot be reviewed until the associated binder is also submitted.
    • The Department will only accept one filing per 2024 Plan/SADP issuer per market segment.
    • The Department will provide two weeks for issuers to respond to initial objections on rate objections and one week on form objections. Approximately 30 days prior to the federally imposed disposition deadlines, response time frames will be limited to one week or less in some cases. Extensions will not be granted unless there is an extraordinary circumstance.
    • Prior to filing, issuers should review all objections and requests from prior years.The current filing should be amended accordingly to expedite the review of the filing.
    • When the final guidance is released, we will post the 2023 Filing Requirements (for 2024 Plans) chart on our website.Changes, updates, and new requirements for PY 2024 will be outlined in this document.It is imperative that the most recent guidelines are followed to maintain accuracy and completeness of the filing.
    • The Department will publish additional guidance as necessary on its LA&H webpage under the PPACA Resources heading, which may be accessed at doi.sc.gov/lah.
    • The information in this Memorandum is based on the Final Key Dates for Calendar Year 2023. Please check our website often for the latest updates

    Issuers should regularly check the LA&H webpage (doi.sc.gov/lah) for additional materials relative to the filing and review process.Please note that all materials will be listed under the PPACA Resources heading.

    Questions should be submitted via email to lahmail@doi.sc.gov and include the company name and  primary point of contact (with phone number and email address).

  • 7 Apr 2023 9:03 AM | Addie Thompson (Administrator)

    For decades, U.S. hospitals have generally stonewalled patients who wanted to know ahead of time how much their care would cost. Now that’s changing — but there’s a vigorous debate over what hospitals are disclosing.

    Under a federal rule in effect since 2021, hospitals nationwide have been laboring to post a mountain of data online that spells out their prices for every service, drug, and item they provide, including the actual prices they’ve negotiated with insurers and the amounts that cash-paying patients would be charged. They’ve done so begrudgingly and only after losing a lawsuit that challenged the federal rule.

    How well they’re doing depends on whom you ask.

    The rule aims to pull back the curtain on opaque hospital prices that may vary widely by hospital for the same service or even within the same hospital. The expectation is that price transparency will boost competition, giving consumers and employers a way to compare prices and make informed choices, ultimately driving down the cost of care. Whether that will happen is not yet clear.

    Insurers and large employers are also required to post their negotiated prices with all their providers, under separate rules that took effect last summer.

    Hospitals have made “substantial progress,” according to an analysis by the federal Centers for Medicare & Medicaid Services of 600 randomly selected hospitals that was published in the journal Health Affairs last month. The agency looked at whether hospitals had met their obligation to post price information online in two key formats: a “shoppable” list of at least 300 services for consumers, and a comprehensive machine-readable file that incorporates all the services for which the hospital has standard charges. This file should be in a format that allows researchers, regulators, and others to analyze the data.

    CMS found that 70% of hospitals published both lists in 2022. An additional 12% published one or the other. By contrast, the agency’s previous progress assessment in 2021 found that just 27% of 235 hospitals had both types of lists.

    The 2022 analysis “represents a marked improvement,” said Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at CMS, in a statement. But she also said the advances are still “not sufficient” and CMS will continue to use “technical assistance and enforcement activity” so that all hospitals “fully comply with the law.”

    The American Hospital Association said the CMS assessment demonstrated the progress hospitals had made under very challenging circumstances as they grappled with the covid-19 pandemic.

    “These are complicated policies that went into effect in the most complicated time in hospitals’ history,” said Molly Smith, group vice president for policy at the trade association. “And we have seen increases in compliance over the past 18 months.”

    Some groups that have looked at the hospitals’ posted price data, though, were less upbeat. In an analysis published last month, Patient Rights Advocate examined 2,000 hospitals’ listings and found that only 489 of them, 24.5% of the total, were compliant with all the requirements of the rule. An earlier analysis in August 2022 found that 16% met all the requirements.

    The advocacy group’s analysis covered not only the two types of lists that CMS looked for but also checked whether the hospitals included required data on specific types of standard charges for every service offered, such as the gross or “chargemaster” charge before any discounts are applied, the discounted cash price, and the negotiated charge by insurer.

    Although most hospitals have published files online, too often the data is incomplete, illegible, or not clearly associated with specific health plans or insurers, said Cynthia Fisher, founder and chair of Patient Rights Advocate, which promotes health care price transparency.

    “As hospitals continue to post incomplete files with swaths of missing prices, patients are unable to accurately compare prices across hospitals and across plans to make the best health care decisions and protect themselves from overcharges,” Fisher said. Such hospitals were considered noncompliant in the PRA analysis.

    The hospital association faulted PRA’s analysis. The contracts that hospitals have with health plans vary substantially from one to the next, and prices are not always based on a simple dollar amount, said Terry Cunningham, AHA’s director of policy. They might be based on a bundle of services or on volume, for example, he said.

    “It’s both frustrating and problematic for these other organizations to be weighing in, saying, ‘This cell shouldn’t be blank,’” Cunningham said.

    In their 2020 lawsuit, hospitals argued that they should not be required to disclose privately negotiated prices, and maintained that doing so would confuse patients and lead to anti-competitive behavior by insurers.

    Last summer, price transparency requirements took effect in the health insurance industry as well, complementing and providing a cross-reference tool for what hospitals have posted. The insurer transparency requirements are even broader than those for hospitals: Insurers and self-funded employers must list every negotiated rate they have with every doctor, hospital, and other health care providers.

    Some critics charge that data isn’t user-friendly either. Sens. Maggie Hassan (D-N.H.) and Mike Braun (R-Ind.) sent a letter March 6 to CMS Administrator Chiquita Brooks-LaSure encouraging the agency to take steps to close “technical loopholes” such as large files and a lack of standardization that make it difficult to use the data they’re reporting.

    That’s where pricing platforms like Turquoise Health come in. The data becoming available from hospitals and insurers is a vast treasure trove the company is mining to devise user-friendly tools that consumers and businesses can use to discover and compare prices.

    In its own analysis of how effective hospital price transparency efforts were in 2022’s third quarter, Turquoise Health found that 55% of the more than 4,900 acute care hospitals that posted machine-readable files were “complete,” meaning they posted the cash, list, and negotiated rates for a “significant quantity” of items and services. Twenty-four percent of hospitals were judged to be “mostly complete.” (The analysis didn’t evaluate the second type of posting, the list of shoppable services.)

    According to Chris Severn, Turquoise Health co-founder and CEO, the company uses a scoring algorithm of 60 variables to assess how complete a hospital’s file is.

    “What you end up with is a more nuanced look at these files that hopefully takes into consideration shades of gray,” Severn said, rather than a simple pass-fail rating.

    Regardless of the differences in how the hospital disclosures are evaluated, experts generally agree that CMS should require data be reported in a standardized format for ease of comparison and enforcement. CMS has developed a template, but hospitals aren’t required to use it.

    For price transparency to work, enforcement also needs consistent attention, experts say. The Biden administration increased the maximum potential penalty to more than $2 million annually per hospital for 2022. Still, last year CMS penalized just two hospitals for noncompliance even though 30% of hospitals didn’t meet the requirement to post both a machine-readable file of prices as well as a shoppable list.

    CMS provided technical assistance to many hospitals to help them come into compliance, said Seshamani, and it also plans stronger enforcement actions.

    She said the agency will “continue to expedite” the time frame hospitals have to reach full compliance after submitting a corrective action plan, which indicates they have fallen short on some posting requirements. “CMS also plans to take aggressive additional steps to identify and prioritize action against hospitals that have failed entirely to post files,” she said.

  • 7 Apr 2023 9:02 AM | Addie Thompson (Administrator)

    March 29 (Reuters) - UnitedHealth Group Inc (UNH.N) said on Wednesday its insurance unit will reduce the use of prior authorization process by 20% for some non-urgent surgeries and procedures.

    Under this process, Healthcare providers get coverage approval for certain non-emergency procedures.

    The reductions will begin in the third quarter and will continue through the rest of the year for most commercial and Medicare Advantage as well as Medicaid businesses.

    The company will implement in early next year a national Gold Card Program for care providers that meet eligibility norms, ending the need for prior authorization for most procedures. It would apply for most UnitedHealthcare members.

    "We will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure," said Anne Docimo, chief medical officer of UnitedHealthcare.

    The company said it plans to remove prior authorization requirements in certain types of medical equipment like orthopedic support devices and some genetic tests used for diagnosis.

    The U.S. Centers for Medicare & Medicaid Services had last year issued a proposed rule to simplify the process, which doctors said causes administrative burden to patients and doctors.

  • 5 Apr 2023 12:30 PM | Addie Thompson (Administrator)

    During the tech giant’s annual healthcare event on Tuesday, Google also shared an a updated version of its medical artificial intelligence that can answer clinical questions at an “expert” level.

    Google announced slew of new health initiatives on Tuesday, including bolstering Search to help Medicaid enrollees during redeterminations, an updated version of its medical artificial intelligence that can answer clinical questions and a digital health app development infrastructure.

    Among the other announcements during the tech giant’s annual healthcare event, Google said it will make Medicaid information easier to find on Search for people looking to re-enroll once states resume their eligibility checks. The checks, which were paused during the COVID-19 public health emergency, will resume in April and could cause some 18 million Americans to lose Medicaid coverage.

    When consumers search for a Medicaid-related term on Google, they’ll see a new Renewal tab which will include results on the renewal guidelines in their state, and other information on Medicaid like contact information or the log-in to their state portal. The update will roll out it in the coming weeks, according to a spokesperson.

    Google also plans to highlight providers that are community health centers offering free or low-cost care on search, building on a search engine feature that shows consumers available appointment times for select providers.

    Google frequently cites data that most people use the internet first when checking symptoms or researching medical information. In late 2021, the company wove additional information into practices’ business profiles, including whether they accept Medicare and what languages they offer services in.

    Google launched the booking functionality last year. It shows appointments for CVS MinuteClinics and links with scheduling tools like Kyruus and Stericycle so their provider users can integrate their appointment times into the search engine.

    The bookings functionality only shows appointments at specific practices and does not aggregate across providers.

    On Tuesday, Google said it was expanding the network of qualified partners in the U.S. who can show their appointment availability directly on Search, and make it simpler for them to self-onboard, in the coming months.

    AI and app development

    Google also announced a number of updates to AI projects.

    In partnership with Mayo Clinic, Google has been testing how AI can support planning for radiotherapy, a common cancer treatment. Google said it will soon publish research on the findings of a study into AI’s efficacy in “contouring,” a process where clinicians draw lines on a CT scan to separate healthy tissue from areas of cancer that can take up to seven hours for one patient.

    Google and Mayo Clinic are also formalizing their partnership to explore further research, along with model development and commercialization, according to Greg Corrado, who leads health AI at Google.

    Also on the AI front, Google has invested in medical large language model research to develop AI tools that can retrieve medical information and accurately answer medical questions. Its model, called Med-PaLM, recently ​​​​performed at an “expert” doctor level on medical exam questions, scoring 85%. That’s an 18% improvement from Med-PALM’s previous performance and a result that “far surpasses similar AI models,” Corrado wrote in a blog post on the news.

    However, there’s more work to be done to ensure Med-PaLM will work in real-world settings, said Alan Karthikesalingam, a research lead at Google. An evaluation of the AI found significant gaps when it comes to the complexity of medical questions answered and meeting product excellence standards.

    Google also announced a number of new partners for AI research, including Kenya-based nonprofit Jacaranda Health on ultrasound delivery for expectant mothers, Chang Gung Memorial Hospital in Taiwan on ultrasound for breast cancer detection and nonprofit Right to Care on AI-powered chest x-ray screening to help with tuberculosis in Africa.

    The tech giant introduced a suite of open-source infrastructure built on an interoperable data standard to make it easier for developers to quickly build healthcare apps.

    Despite disbanding its health-specific unit in 2021, Google has remained active in the healthcare industry, launching tools to help healthcare companies make their medical images more actionable through AI and machine learning and inking a deal with major EHR vendor Meditech to embed its clinical software tools into the records of U.S. hospitals.

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