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

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

Form Details:

  • Released on March 10, 2020;
  • The latest edition currently provided by the Kansas Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kansas Insurance Department.

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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.
2021 FINAL ISSUERS LETTER
1. PEDIATRIC DENTAL ESSENTIAL HEALTH BENEFIT: COMPANY attests that its submitted
SADPs provide coverage for the pediatric dental essential health benefit in accordance with the
Kansas benchmark plan and federal law.
2. 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.
3. 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) & K.S.A. 40-4607 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.
4. 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.
5. 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.
6. SERVICE AREA: COMPANY attests that its service areas are composed of no less than whole
counties.
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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.
2021 FINAL ISSUERS LETTER
1. PEDIATRIC DENTAL ESSENTIAL HEALTH BENEFIT: COMPANY attests that its submitted
SADPs provide coverage for the pediatric dental essential health benefit in accordance with the
Kansas benchmark plan and federal law.
2. 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.
3. 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) & K.S.A. 40-4607 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.
4. 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.
5. 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.
6. SERVICE AREA: COMPANY attests that its service areas are composed of no less than whole
counties.
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7. 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.
8. NON-DISCRIMINATION: COMPANY attests it does not, with respect to its SADP, discriminate on
or
the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation
health status
as required in 45 CFR 156.200(e).
KANSAS PROVIDER MANDATES
9. SERVICES BY OPTOMETRIST, DENTIST OR PODIATRIST: COMPANY attests that its QHP
submissions are in compliance with K.S.A. 40-2,100.
10. SCOPE OF PRACTICE UNDER KANSAS HEALING ARTS ACT: COMPANY attests that its QHP
submissions are in compliance with K.S.A. 40-2,101.
11. SERVICES BY LICENSED PSYCHOLOGIST: COMPANY attests that its QHP submissions are in
compliance with K.S.A. 40-2,104.
12. SERVICES BY LICENSED SPECIALIST SOCIAL WORKER: COMPANY attests that its QHP
submissions are in compliance with K.S.A. 40-2,114.
13. SERVICES BY ADVANCED PRACTICE REGISTERED NURSES: COMPANY attests that its
QHP submissions are in compliance with K.S.A. 40-2250.
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
2021_QHP_Dent_Attest v1.0, 03/10/2020
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