Service Area Instructions for a Qualified Health Plan

CFR › Title 45 › Subtitle A › Subchapter B › Part 155 › Subpart K › Section 155.1055

45 CFR 155.1055 - Service area of a QHP.

§ 155.1055 Service area of a QHP.
The Exchange must have a process to establish or evaluate the service areas of QHPs to ensure such service areas meet the following minimum criteria:
(a) The service area of a QHP covers a minimum geographical area that is at least the entire geographic area of a county, or a group of counties defined by the Exchange, unless the Exchange determines that serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of the qualified individuals and employers.
(b) The service area of a QHP has been established without regard to racial, ethnic, language, health status-related factors specified under section 2705(a) of the PHS Act, or other factors that exclude specific high utilizing, high cost or medically-underserved populations.

I. Instructions for All QHP Service Areas

For each QHP service area, please submit a statement describing the process used to designate the service area and demonstrating that the service area has not been designated in consideration of racial, ethnic, language and health related factors, or any other factors that exclude specific high utilizing, high cost, or medically underserved populations. The carrier should include facts detailing how the counties in the service area were chosen, and demonstrating that service area boundaries were not drawn in consideration of prohibited factors.

The Minnesota Department of Health reserves the right to request additional information from carriers to evaluate whether the service area meets these requirements.

II. Instructions for QHP Service Areas Less Than One Full County (Partial Counties)

In general, service areas are expected to include at least the entire geographic area of a county. If a QHP proposed service area consists of a partial county, the carrier must submit the following information:

a. A county map with the portion of the county the QHP will serve outlined;
b. A statement, demonstrating with specific facts that serving only part of the county is:

a. Necessary; and
b. In the best interests of qualified individuals and employers; and
c. Non-discriminatory. This may be demonstrated with facts showing that the anticipated cost of care in the proposed service area is the
same as for the area that is excluded, or that the racial and economic composition of the population in the proposed service area is the same as for the area that is excluded

This information should be submitted through SERFF in the “supporting documentation” function.

The Minnesota Department of Health reserves the right to request additional information from carriers to evaluate whether the service area meets these requirements.

Updated Thursday, 16-May-2013 09:26:54 CDT