Checklist for Individual and Small Group MEDICAL Plans FORMS Effective for Plan Years beginning on or after January 1, 2019 (See FIS 2305 (3/18) for Stand-alone Dental Plans Forms Checklist) Issuer Name: Market: Individual Small Group On/Off Marketplace Off Marketplace Forms Contact Person: (provide Phone Number: Email address: two) Forms Contact Person: Phone Number: Email address: Third Party Filer: Phone Number: Email address: (if applicable) Each product must offer every item and service covered in the Michigan Benchmark Plan as supplemented by the MIChild Dental program (for pediatric dental coverage) and the federal FEDVIP Blue Vision High Option Plan (for pediatric vision coverage). Information on the 2017 Benchmark Plan benefits is available through CCIIO at: . Health Plan Submission Guidelines can be referenced in the recently published DIFS Bulletin: BULLETIN 2018-07-INS Health Forms Checklist Instructions: NOTES: A separate checklist form is required for Individual and Group forms filings offered by an Issuer. All Forms and associated rates must be filed together in the same SERFF filing. This checklist is to be uploaded in SERFF under the supporting documentation tab of the forms/rates filing. The required format for saving this checklist is: CompanyName_MIMedicalFormsChecklist_Version number. The initial filing will be identified as Version 1. Any changes to the responses in this checklist form must be re-filed, and must include the updated version number. As used in this checklist, Document” includes all forms required to be filed in SERFF. “Coverage Applicable federal and state laws and regulations supersede this checklist in the case of a conflict. The omission of any requirement of law or regulation does not limit DIFS’ authority to enforce. The filing must include summaries of benefits and coverage (SBCs) in the format required for use after 4/1/17. Section A. Contract Requirements
Checklist for Individual and Small Group MEDICAL Plans FORMS Effective for Plan Years beginning on or after January 1, 2019 (See FIS 2305 (3/18) for Stand-alone Dental Plans Forms Checklist) Issuer Name: Market: Individual Small Group On/Off Marketplace Off Marketplace Forms Contact Person: (provide two) Phone Number: Email address: Forms Contact Person: Phone Number: Email address: Third Party Filer: (if applicable) Phone Number: Email address: Each product must offer every item and service covered in the Michigan Benchmark Plan as supplemented by the MIChild Dental program (for pediatric dental coverage) and the federal FEDVIP Blue Vision High Option Plan (for pediatric vision coverage). Information on the 2017 Benchmark Plan benefits is available through CCIIO at: . Health Plan Submission Guidelines can be referenced in the recently published DIFS Bulletin: BULLETIN 2018-07-INS Health Forms Checklist Instructions: NOTES: A separate checklist form is required for Individual and Group forms filings offered by an Issuer. All Forms and associated rates must be filed together in the same SERFF filing. This checklist is to be uploaded in SERFF under the supporting documentation tab of the forms/rates filing. The required format for saving this checklist is: CompanyName_MIMedicalFormsChecklist_Version number. The initial filing will be identified as Version 1. Any changes to the responses in this checklist form must be re-filed, and must include the updated version number. As used in this checklist, “Coverage Document” includes all forms required to be filed in SERFF. Applicable federal and state laws and regulations supersede this checklist in the case of a conflict. The omission of any requirement of law or regulation does not limit DIFS’ authority to enforce. The filing must include summaries of benefits and coverage (SBCs) in the format required for use after 4/1/17. Section A. Contract Requirements
Checklist_Medical_Form_555752_7.docx