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Judicial Watch • Providence Health Plan Documents from Oregon

Providence Health Plan Documents from Oregon

Providence Health Plan Documents from Oregon

Page 1: Providence Health Plan Documents from Oregon

Category:FOIA Response

Number of Pages:15

Date Created:November 25, 2013

Date Uploaded to the Library:December 16, 2013

Tags:ACA, SRRHIC, obamacare, Oregon


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SERFF Tracking PROV-129121711
State Tracking PROV-129121711
State:
Oregon
TOI/Sub-TOI:
Filing Company:
H06 Health Conversion/H06.000 Health Conversion
Product Name:
Company Tracking 90-DAY DISCONTINUANCE
FILING_PROVIDENCE_...
Providence Health Plan
90-day Discontinuance Filing_Providence_Portability_123113
Project Name/Number: 90-day Discontinuance Filing_Providence_Portability_123113/90-day Discontinuance Filing_Providence_Portability_123113
Filing Glance
Company:
Product Name:
State:
TOI:
Sub-TOI:
Filing Type:
Date Submitted:
SERFF Num:
SERFF Status:
State Num:
State Status: Num:
Providence Health Plan
90-day Discontinuance Filing_Providence_Portability_123113
Oregon
H06 Health Conversion
H06.000 Health Conversion
Form
08/16/2013
PROV-129121711
Closed-Filed information
PROV-129121711
Review completed
90-DAY DISCONTINUANCE FILING_PROVIDENCE_PORTABILITY_123113
Implementation
Date Requested:
Author(s):
Reviewer(s):
Disposition Date:
Disposition Status:
Implementation Date:
12/31/2013
Eda-Marie Johnson, Dave Nesseler-Cass, Penny Cadaret, Michelle Dodge
Rhonda Saunders-Ricks (primary)
08/28/2013
Filed information
08/28/2013
State Filing Description:
PDF Pipeline for SERFF Tracking Number PROV-129121711 Generated 11/25/2013 05:31
SERFF Tracking PROV-129121711
State Tracking PROV-129121711
State:
Oregon
TOI/Sub-TOI:
H06 Health Conversion/H06.000 Health Conversion
Product Name:
Company Tracking 90-DAY DISCONTINUANCE
FILING_PROVIDENCE_...
Filing Company:
Providence Health Plan
90-day Discontinuance Filing_Providence_Portability_123113
Project Name/Number: 90-day Discontinuance Filing_Providence_Portability_123113/90-day Discontinuance Filing_Providence_Portability_123113
General Information
Project Name: 90-day Discontinuance
Filing_Providence_Portability_123113
Project Number: 90-day Discontinuance
Filing_Providence_Portability_123113
Requested Filing Mode: Review Approval
Explanation for Combination/Other:
Submission Type: New Submission
Overall Rate Impact:
Deemer Date:
Submitted By: Penny Cadaret
Status Filing Domicile:
Date Approved Domicile:
Domicile Status Comments:
Market Type: Individual
Individual Market Type: Individual
Filing Status Changed: 08/28/2013
State Status Changed: 08/28/2013
Created By: Penny Cadaret
Corresponding Filing Tracking Number:
PPACA: Non-Grandfathered Immed Mkt Reforms
PPACA Notes: null
Include Exchange Intentions:
Filing Description:
90-day Discontinuance filing for Portability plans effective December 31, 2013.
Company and Contact
Filing Contact Information
Penny Cadaret, Compliance Specialist
3601 Murray Blvd
Beaverton, 97005
Filing Company Information
Providence Health Plan
3601 Murray Blvd., Ste.
Portland, 97005
(503) 574-7500 ext. [Phone]
penny.cadaret@providence.org
503-574-5594 [Phone]
CoCode: 95005
Group Code:
Group Name:
FEIN Number: 93-0863097
State Domicile: Oregon
Company Type: HCSC
State Number:
Filing Fees
Fee Required?
Retaliatory?
Fee Explanation:
State Specific
PDF Pipeline for SERFF Tracking Number PROV-129121711 Generated 11/25/2013 05:31
SERFF Tracking PROV-129121711
State Tracking PROV-129121711
State:
Oregon
TOI/Sub-TOI:
Filing Company:
H06 Health Conversion/H06.000 Health Conversion
Product Name:
Company Tracking 90-DAY DISCONTINUANCE
FILING_PROVIDENCE_...
Providence Health Plan
90-day Discontinuance Filing_Providence_Portability_123113
Project Name/Number: 90-day Discontinuance Filing_Providence_Portability_123113/90-day Discontinuance Filing_Providence_Portability_123113
Have you reviewed the General Instructions attached separate pdf the bottom the General Instructions page?: Yes
Did you read the instructions regarding how enter the form number and edition date the Forms Schedule tab?: Yes
Did you realize Oregon does not respond Status Requests thru SERFF?: Yes
Please confirm that you have read the Fraud Bulletin 2010-3 located at:
http://www.cbs.state.or.us/external/ins/bulletins/bulletin2010-03.pdf: Yes
Have you attached under the Supporting Documentation tab any state specific Amendatory Endorsements that will used
bring the submitted forms into compliance with our statutes?: Yes
PDF Pipeline for SERFF Tracking Number PROV-129121711 Generated 11/25/2013 05:31
SERFF Tracking
PROV-129121711
State Tracking
PROV-129121711
Company Tracking
Filing Company:
90-DAY DISCONTINUANCE
FILING_PROVIDENCE_...
State:
Oregon
TOI/Sub-TOI:
H06 Health Conversion/H06.000 Health Conversion
Providence Health Plan
Product Name:
90-day Discontinuance Filing_Providence_Portability_123113
Project Name/Number:
90-day Discontinuance Filing_Providence_Portability_123113/90-day Discontinuance Filing_Providence_Portability_123113
Correspondence Summary
Dispositions
Status
Filed
information
Created
Rhonda Saunders-Ricks
Created
08/28/2013
PDF Pipeline for SERFF Tracking Number PROV-129121711 Generated 11/25/2013 05:31
Date Submitted
08/28/2013
SERFF Tracking
PROV-129121711
State Tracking
PROV-129121711
Company Tracking
Filing Company:
90-DAY DISCONTINUANCE
FILING_PROVIDENCE_...
State:
Oregon
TOI/Sub-TOI:
H06 Health Conversion/H06.000 Health Conversion
Providence Health Plan
Product Name:
90-day Discontinuance Filing_Providence_Portability_123113
Project Name/Number:
90-day Discontinuance Filing_Providence_Portability_123113/90-day Discontinuance Filing_Providence_Portability_123113
Disposition
Disposition Date: 08/28/2013
Implementation Date: 08/28/2013
Status: Filed information
HHS Status: Not Reported
State Review:
Comment:
Rate data does NOT apply filing.
Schedule
Supporting Document
Supporting Document
Supporting Document
Supporting Document
Supporting Document
Supporting Document
Supporting Document
Supporting Document
Schedule Item
Cover Letter Explanatory Memorandum
Third party filers letter authorization
3894 Certification Compliance
3049 Standards for Portability
3899 Readability Certification
2896 Benefit Modification Discontinuance Health
Benefit Plans
Highlighted/Redline form version replaced, amended similar forms
Letter policyholder
Schedule Item Status
Reviewed-No Action
Reviewed-No Action
Reviewed-No Action
Reviewed-No Action
Reviewed-No Action
Information only
Public Access
Yes
Yes
Yes
Yes
Yes
Yes
Reviewed-No Action
Yes
Information only
Yes
PDF Pipeline for SERFF Tracking Number PROV-129121711 Generated 11/25/2013 05:31
SERFF Tracking
PROV-129121711
State Tracking
PROV-129121711
Company Tracking
Filing Company:
90-DAY DISCONTINUANCE
FILING_PROVIDENCE_...
State:
Oregon
TOI/Sub-TOI:
H06 Health Conversion/H06.000 Health Conversion
Providence Health Plan
Product Name:
90-day Discontinuance Filing_Providence_Portability_123113
Project Name/Number:
90-day Discontinuance Filing_Providence_Portability_123113/90-day Discontinuance Filing_Providence_Portability_123113
Supporting Document Schedules
Satisfied Item:
Comments:
Attachment(s):
Item Status:
Status Date:
Cover Letter Explanatory Memorandum
Please see filing description
Bypassed Item:
Bypass Reason:
Attachment(s):
Item Status:
Status Date:
Third party filers letter authorization
Satisfied Item:
Comments:
Attachment(s):
Item Status:
Status Date:
3894 Certification Compliance
Please see attached
Certificate Compliance.pdf
Reviewed-No Action
08/28/2013
Bypassed Item:
Bypass Reason:
Attachment(s):
Item Status:
Status Date:
3049 Standards for Portability Portability Product being discontinued
Bypassed Item:
Bypass Reason:
Attachment(s):
Item Status:
Status Date:
3899 Readability Certification
Satisfied Item:
Comments:
Attachment(s):
Item Status:
2896 Benefit Modification Discontinuance Health Benefit Plans
Please see attached
Portability Form 2896.pdf
Information only
Reviewed-No Action
08/28/2013
Reviewed-No Action
08/28/2013
Reviewed-No Action
08/28/2013
Reviewed-No Action
08/28/2013
PDF Pipeline for SERFF Tracking Number PROV-129121711 Generated 11/25/2013 05:31
SERFF Tracking
PROV-129121711
State Tracking
PROV-129121711
Company Tracking
Filing Company:
90-DAY DISCONTINUANCE
FILING_PROVIDENCE_...
State:
Oregon
TOI/Sub-TOI:
H06 Health Conversion/H06.000 Health Conversion
Providence Health Plan
Product Name:
90-day Discontinuance Filing_Providence_Portability_123113
Project Name/Number:
90-day Discontinuance Filing_Providence_Portability_123113/90-day Discontinuance Filing_Providence_Portability_123113
Status Date:
08/28/2013
Bypassed Item:
Bypass Reason:
Attachment(s):
Item Status:
Status Date:
Highlighted/Redline form version replaced, amended similar forms
Satisfied Item:
Comments:
Attachment(s):
Item Status:
Status Date:
Letter policyholder
Please see attached
Portability Discontinuation letter_FINAL.pdf
Information only
08/28/2013
Reviewed-No Action
08/28/2013
PDF Pipeline for SERFF Tracking Number PROV-129121711 Generated 11/25/2013 05:31
Department Consumer Business Services
Oregon Insurance Division
350 Winter St.,
Salem, Oregon 97301-3883
Phone: (503) 947-7983
TRANSMITTAL AND REQUIREMENTS FOR
MODIFICATION AND DISCONTINUANCE HEALTH BENEFIT PLANS defined ORS 743.730(19)(a)
Date: 8/16/2013
NAIC No:95005
Insurer name:Providence Health Plan
Filing entity name (if not insurer):
Department Action:
 Approved;
Limitations_______________
________________________ not the insurer, letter authorization must included the filing.
 Processed Information
Contact person name:Penny Cadaret
 Withdrawn
Title:Commercial Compliance Specialist
 Disapproved;
Mailing address:PO Box 4327 Portland 97208-4237
Reason: _________________
_______________________
Action Date: _______________
Toll-free/collect phone no.:800-878-4445
Email address:penny.cadaret@providence.org
Effective date:12/31/2013
Effective Date: _____________ different from action date
Analyst: ___________________
State Filing No.:_____________
This filing submitted for:
MODIFICATION OAR 836-053-0001 (complete Section III, and IV)
DISCONTINUANCE ORS 743.737; 743.754; 743.766 (complete Section II, III, and IV)
Patient Protection Affordability Care Act (PPACA)
Plan(s) are:
Non-Grandfathered
Grandfathered grandfathered the plans are:
Losing Grandfathered status
Maintaining Grandfathered status
The following checklist standards help carriers make complete filing compliance with
relevant statutes and rules. some cases, the statements contained this form are summaries and may necessary refer the entire statute rule. The filer signature the certification form confirmation that diligent consideration has been given each item. the case modification,
replacement rates and forms must submitted with this transmittal document.
440-2896 (rev. 3/13/INS)
MODIFICATION OAR 836-053-0001 modification change changes that alter the actuarial valuation the health benefit
plan less than 10% the aggregate the policyholder.
 Modifications can only implemented the time renewal. notice explaining all changes must sent all policyholders least days prior
their renewal date. OAR 836-053-0001(3) Please select the type(s) health plan involved
Small employer group health benefit plan
Large group health benefit plan
Individual health benefit plan
Portability health benefit plan Please select the type modification that applies:
Eliminating adding benefits services payable health benefit plan
Increasing decreasing benefits payable services under plan, including decrease increase that occurs result change formulas, methodologies schedules
that serve the basis for making benefit determinations.
Increasing decreasing deductibles, copayments other amounts paid
enrollee.
Establishing new conditions requirements such preauthorization requirements
obtain services benefits under the plan eliminating such conditions requirements. ORS 742.003(4) Prior issuing notices: Include copy the notice that will sent policyholders renewal advising them the modification(s) their plan. the case group plan, carrier plans notify subscribers, include copy the
notice that advises them the modification(s) their plan renewal. For Individual plan modifications, include copy the notice that will sent
policyholders.
Continue Section III.
440-2896 (3/13/INS)
II.
DISCONTINUANCE ORS 743.737; 743.754; 743.766 Please select the type health plan involved:
Small employer health benefit plan
Large employer health benefit plan
Individual health benefit plan
Portability health benefit plan carrier discontinuing all the group products this state, separate Portability
discontinuance filing must submitted. there are other group products and result,
Portability plans cannot continued, carriers may offer enrollees their Individual plans with health status underwriting well the option obtain coverage through the Oregon
Medical Insurance Pool (OMIP). Does the carrier have other group products this state? yes,
small
large
Yes
both large and small group
Corresponding portability plan(s) discontinuation filing included under separate cover. Portability discontinuation filing not included this filing under separate cover,
please explain why: Does the carrier have individual products this state?
Yes
a.) yes, will the carrier offer the portability members the individual plan
 
without medical underwriting
 
with medical underwriting
The carrier discontinuing offering renewing, offering and renewing all health
benefit plans specified area(s) within Oregon. Which counties are affected?
The carrier discontinuing offering renewing, offering and renewing health benefit
plan Oregon.
The carrier discontinuing offering renewing, offering and renewing health benefit
plan specified area(s) within Oregon. Which counties are affected?(closed block) ORS 742.003(4) Prior issuing notices:
 Provide copy the notice DCBS for review prior issuing the notices the
policyholders. The notices must provide detailed information regarding the
policyholder options.
440-2896 (3/13/INS)
III.
REQUIRED SUPPORTING DOCUMENTATION
List all plans being discontinued modified and provide the number policyholders each
plan involved. (Attach additional page needed)
Plan and Form Number Grandfathered
Name Insured Lives
Yes/No
PORT-OR 0113 EPO-COPAY
HMO 30/500/3000
PORT-OR 0113 EPO-COPAY
HMO 30/100/1500
250
PORT-OR 0113 POS
POS 20/40/15000 750d
762
PORT-OR 0113 POS
POS 30/50/20000 1500d
373
PORT-OR 0113 INDEMNITY
INDEM 20/15000 750d
PORT-OR 0113 INDEMNITY
INDEM 30/20000 1500d
PORT-OR 0113 PLAN 20/40/60
1013
PORT-OR 0113 PLAN 20/40/60 1000d
409
IV. Items required filing, whether modification discontinuance: actuarial demonstration describing the changes benefits and/or rates.
Include chart showing claim cost percentages premium for all the added
discontinued benefits and/or services and the sum the changes. Note: the idea here prove modification (less than 10%) discontinuance (more than 10%). The same
service can have different dollar values depending other provisions such
deductibles. need the overall effect, best stated percentage including the
percentage for each item the list that represents the items portion the total premium. this information not included the filing, please provide written explanation.
Provide description the data (source and time period) used develop the value for
the benefits and/or services. list the changes the modification including side-by-side comparison showing the
previous benefit structure compared the new benefit structure. side-by-side comparison showing the new plan that will closest the discontinued.
Language changes that constitute benefit service change must included the
side-by-side comparison.
Provide statement why the changes are needed. All portability plans are being
discontinued per 2240.
Carriers are subject 5-year ban from the Oregon market product line they elect
discontinue.
440-2896 (3/13/INS)
Small Employer ORS 743.736(12)
Large Group ORS 743.752(2)
Individual ORS 743.769(6)
440-2896 (3/13/INS)
[PHP logo bw]
[date]
[subscriber name
subscriber address]
Re: Portability Plan Discontinuation
Dear [First name Last name]:
Thank you for choosing Providence Health Plan your trusted partner. committed
doing right you, and your well-being. the major changes health care reform roll out, want make sure that you have all the information you need make the health plan
choice that right for you.
The first thing you need know that, due changes related the Affordable Care Act,
ACA, all portability plans, including your existing plan, will discontinued after Dec. 31, 2013
and, therefore, you will need choose new health plan coverage. The good news that
individuals longer will denied coverage due pre-existing conditions. That means you able get individual health insurance coverage even you were previously denied and you
can charged more you have significant health issues. Providence offers wide variety
new individual plans that include richer benefits and new limits out-of-pocket costs. New
plans are available with coverage effective early Jan. 2014. still your partner
While the ACA does require change from your current plan, doesn require you change
the way you about getting coverage. You can still buy your plan from us, you done
before. You will continue receive the personal level care that you come expect from
Providence. And now, you also able select from new individual plans offering wide
variety advantages support your well-being, such as: connected care experience delivered exclusive community primary care
providers and specialists who work together support your health
Hundreds classes and seminars topics such brain health, stress management,
weight control and quitting smoking, promote mind and body health
Exclusive discounts recreation, cultural activities and travel, including savings
hotels, cruises and tickets local events
Providence repeatedly ranked one the most well-integrated health care systems the
nation. Providence Health Plan member, that means you can enjoy superior customer
service and peace mind knowing that your physicians, hospitals, pharmacies and health plan
teams are all working together keep you healthy possible. Providence about more
than technology and tools, numbers and claims. about ensuring your greater good.
been serving Oregonians and the Pacific Northwest since 1856, and here for the long haul.
What you need next
Please review the enclosed plan information provided help you choose new Providence plan
that best fits your health insurance needs. Plan and enrollment information also available
online [URL]. Once you chosen your new health plan, simply submit your completed
application either online mail.
The timeframe during which you may purchase coverage for 2014, called open enrollment, will
begin October 2013 and end March 31, 2014. you purchase policy through Oregon
health insurance exchange, called Cover Oregon, you may eligible for subsidy and/or tax
credits based your income. Contact Cover Oregon 855-COVEROR (855-268-3767) your
insurance producer for more information.
Questions? Give call
There lot information here, and know can pretty overwhelming. Rest assured that are here guide you through it. you have any questions about the discontinuation your
current plan, your new plan options, health care reform changes, anything this packet,
will more than happy explain it. speak with Sales representative, please call 800-988-0088 (TTY: 711), Monday through
Friday between a.m. and p.m.
Sincerely,
Doug Dillon
Director, Individual and Medicare Sales
[Enclosure(s)]



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