"Qualified Heath Plan (Qhp) Submission Attestation Form" - Kansas

Qualified Heath Plan (Qhp) Submission Attestation Form is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

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STATE OF KANSAS
QUALIFIED HEATH PLAN (QHP)
SUBMISSION ATTESTATION FORM
I,
, attest that, to the best of my knowledge and belief, and
by or at the direction of
,
of
(COMPANY),
,
the following information provided in this attestation is true, complete, and accurate. I further understand
that the Kansas Insurance Department may request additional information to substantiate this information.
2020 FINAL ISSUERS LETTER
1. ESSENTIAL HEALTH BENEFITS: COMPANY attests its submitted QHPs provide coverage for
each of the ten statutory categories of essential health benefits (EHB) in accordance with the Kansas
EHB-benchmark plan and federal law.
2. FORMULARY: COMPANY attests its formulary covers the greater of one drug in every USP
category and class, or at least the same number of drugs in each category and class as the EHB-
benchmark plan.
3. LICENSURE AND SOLVENCY: COMPANY attests that it holds a certificate of authority in good
standing with authority to offer for sale health plans in Kansas.
4. NETWORK ADEQUACY: COMPANY attests it will maintain a network that is sufficient in number
and types of providers, including specialists in mental health and substance use disorder services, to
assure that all services will be accessible without unreasonable delay in accordance with 45 C.F.R.
§156.230(a)(2), and will provide both a link to a publicly available website containing the provider
directory as well as a list of providers in compliance with applicable federal regulations.
It is further attested:
The COMPANY is accredited by:
NCQA
URAC
AAAHC
for the following existing line(s) of
Commercial
Medicaid
Exchange
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STATE OF KANSAS
QUALIFIED HEATH PLAN (QHP)
SUBMISSION ATTESTATION FORM
I,
, attest that, to the best of my knowledge and belief, and
by or at the direction of
,
of
(COMPANY),
,
the following information provided in this attestation is true, complete, and accurate. I further understand
that the Kansas Insurance Department may request additional information to substantiate this information.
2020 FINAL ISSUERS LETTER
1. ESSENTIAL HEALTH BENEFITS: COMPANY attests its submitted QHPs provide coverage for
each of the ten statutory categories of essential health benefits (EHB) in accordance with the Kansas
EHB-benchmark plan and federal law.
2. FORMULARY: COMPANY attests its formulary covers the greater of one drug in every USP
category and class, or at least the same number of drugs in each category and class as the EHB-
benchmark plan.
3. LICENSURE AND SOLVENCY: COMPANY attests that it holds a certificate of authority in good
standing with authority to offer for sale health plans in Kansas.
4. NETWORK ADEQUACY: COMPANY attests it will maintain a network that is sufficient in number
and types of providers, including specialists in mental health and substance use disorder services, to
assure that all services will be accessible without unreasonable delay in accordance with 45 C.F.R.
§156.230(a)(2), and will provide both a link to a publicly available website containing the provider
directory as well as a list of providers in compliance with applicable federal regulations.
It is further attested:
The COMPANY is accredited by:
NCQA
URAC
AAAHC
for the following existing line(s) of
Commercial
Medicaid
Exchange
1
5. ESSENTIAL COMMUNITY PROVIDERS: COMPANY attests that it meets the
following requirement for inclusion of Essential Community Providers (ECP):
Achieves 20% ECP participation in network in service area, agrees to offer contracts to at
least one ECP of each type available by county, and agrees to offer contracts to all available
Indian providers.
If the above standard has not been met, has submitted a satisfactory narrative justification
in the ECP Supplemental Response Form included with this filing.
6. MARKETING STANDARDS: COMPANY attests that it will comply with state marketing
standards adopted by K.A.R. 40-9-100 and will provide marketing materials to the Kansas
Insurance Department on request.
7. ACCREDITATION: COMPANY attests that it meets or will meet the timeline for
accreditation established by 45 CFR 155.1045 and authorizes release of its accreditation data.
8. SERVICE AREA: COMPANY attests that its service areas are composed of no less than
whole counties.
9. NON-DISCRIMINATION IN BENEFIT DESIGN: COMPANY attests that it does not employ
marketing practices or benefit designs that will discourage the enrollment of individuals with
significant health needs as required in 45 CFR 156.225.
10. NON-DISCRIMINATION: COMPANY attests it does not, with respect to its QHP, discriminate
on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation
or health status as required in 45 CFR 156.200(e).
11. PATIENT SAFETY STANDARDS: COMPANY attests that it has verified that all contracted
hospitals of greater than 50 beds utilize a patient safety evaluation system as defined in 42 CFR 3.20
and has implemented a comprehensive person-centered discharge program to improve care
coordination and health care quality for each patient as required in 45 CFR 156.1110.
12. QUALITY RATING SYSTEM AND QHP ENROLLEE EXPERIENCE SURVEY: COMPANY
attests that it will comply with the Quality Rating System (QRS) and QHP Enrollee Experience
Survey reporting and implementation requirements pursuant to 45 CFR 156.1120 and 45 CFR
156.1125.
KANSAS PROVIDER MANDATES
13. SERVICES BY OPTOMETRIST, DENTIST OR PODIATRIST: COMPANY attests that its
QHP submissions are in compliance with K.S.A. 40-2,100.
14. SCOPE OF PRACTICE UNDER KANSAS HEALING ARTS ACT: COMPANY attests that its
QHP submissions are in compliance with K.S.A. 40-2,101.
15. SERVICES BY LICENSED PSYCHOLOGIST: COMPANY attests that its QHP submissions are
in compliance with K.S.A. 40-2,104.
16. SERVICES BY LICENSED SPECIALIST SOCIAL WORKER: COMPANY attests that its
QHP submissions are in compliance with K.S.A. 40-2,114.
17. SERVICES BY ADVANCED PRACTICE REGISTERED NURSES: COMPANY attests that
its QHP submissions are in compliance with K.S.A. 40-2250.
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I understand that knowingly providing false information in a matter within the jurisdiction of the
Kansas Insurance Department may result in penalties under K.S.A. 21-5824 and/or K.S.A. 21-
5903. Attester’s typed name below and submission will constitute signature.
Attester’s Name (first, middle, last)
Attester’s Title
Date
2019_QHP_Med_Attest v1.0, Apr. 4, 2017
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