Common use of Diagram Clause in Contracts

Diagram. Filing Revised Versions of Previous Year’s Forms: You may not use Non-Administrative Variability to define product or plan design: Different products must be filed separately. Plans with different benefits are separate products. No benefits (such as adult dental or contraception) may be bracketed in Individual or Small Group plans. Different plans within each product may not be filed using any form of Non-Administrative variability or bracketing. Administrative Variability may be used in Individual or Small Group filings, including necessary Exchange and Off-Exchange eligibility language. Administrative Variability does not require a formal variability statement. Pediatric stand-alone dental plan (with Pediatric Dental EHB) for 2023 plan year: Scope of Section by TOI in SERFF: H10I.001 or H10G.001 Submission Requirements: You must use, with no variations, one of the following naming conventions (as appropriate) in the SERFF Product Name field on the General Information tab: Individual - EHB Dental - Both Inside and Outside Exchange. Individual - EHB Dental - Exchange Only. Individual - EHB Dental - Outside Exchange Only. Small Group - EHB Dental - Both Inside and Outside Exchange. Small Group - EHB Dental - Exchange Only. Small Group - EHB Dental - Outside Exchange Only. In the Corresponding Filing Tracking Number field, list the SERFF Tracking Number(s) of the corresponding rate filing(s) (public and separate not-for-public rate filing, if requested). DO NOT file Large and Small Group products combined. 2023 Cascade Care Standardized and Public Option Health Plans (RCW 43.71.095) Scope of Section by TOI in SERFF: H16I and HOrg02I This section applies to all Standardized (Cascade) and Public Option (Cascade Select) health plans to be offered through the Washington Health Benefit Exchange (WAHBE). Public Option Health Plans must use the Standardized Plan design. Standardized and Public Option Health Plans may only be marketed through the Exchange. Filing Instructions: Forms must be filed according to Section IV of these instructions, with the exception of: Standardized Health Plans: You must use the following naming convention in the Form Name field on the Form Schedule tab: “[Issuer Name] Cascade [Metal Level].” Public Option Health Plans: You must use the following naming convention in the Form Name field on the Form Schedule tab: “[Issuer Name] Cascade Select [Metal Level].” An issuer must contact the Exchange directly to discuss and receive approval from the Exchange to use additional identifying elements or plan marketing names in the naming conventions listed in a. and b. above. Approvals received from the Exchange must be attached to the Supporting Documentation tab. DO NOT submit Schedule of Benefits, or any other form, specific to cost-sharing alternatives, including the cost-sharing reduction (CSR) Silver Variant or Tribal plans. Cost-sharing alternative plan information is represented in the Binder’s Plan & Benefits Template only. Student Health Plans See Form Filings Speed-to-Market Guide, Section XI – Student Health Plans, for additional information regarding expediting review of Student Health Plans. Filing requirements: 2022-2023 school year student health plans filing submissions must be received by May 19, 2022. Forms must be filed separately but concurrently with the rates and network access reports. The network name must be clearly identified in the certificate of coverage/benefit booklet and match the network name filed with the OIC exactly (for example: “Your Provider Network is: ________________.”) Binders are not required for student health plans. “PPACA” field: Populate this field with “Non-Grandfathered Immed Mkt Reform.” More information on the PPACA field is available by clicking on the “What is PPACA” link directly below this field. “Include Exchange Intentions” field: Student health plans should be marked as “No” in this field. The Product Name must have the following naming conventions: “2022-2023 School Year Student Health Plan.” “Corresponding Filing Tracking Number” field: You must complete the “Corresponding Filing Tracking Number” field if there is a required corresponding filing (for example, for-public/not-for-public rate, etc.). (Note that this field can be changed via post-submission update if necessary.) A “Corresponding Filing Tracking Number” is the number for a filing that is required to be filed in relation to the current filing. There is no need to list filings other than rate filings (for example, it’s unnecessary to list all form filings sold to the same group, etc.) A corresponding filing tracking number must be a SERFF tracking number. It cannot be a state tracking number, company tracking number, or form number. If there are too many corresponding filing tracking numbers to be placed in the “Corresponding Filing Tracking Number” field (for example, a proprietary rate filing for a specific group that has multiple products), you may list the corresponding filing tracking numbers in a separate document attached on the Supporting Documentation tab and indicate this in the “Corresponding Filing Tracking Number” field. You may not use bracketing or variability to define product or plan design, including benefits or cost sharing amounts. Limited variability will be accepted for administrative purposes only, such as, but not limited to the following: signature blocks, school name, and street address. Limited variability used for administrative purposes only does not require a formal variability statement. You may attach supporting documentation for a specific form under the Supporting Documentation tab. You may not encrypt or otherwise electronically protect any document filed with OIC for review. We must be able to make a PDF copy of each of your forms. Forms translated from English to another language must be filed according to the requirements of WAC 000-00-000. In your initial submission, all forms that comprise your filing must be in final format and attached on the Form Schedule tab. You must list all filed forms in separate lines on the Form Schedule tab, and enter form numbers correctly. Each form listed on the Form Schedule tab must have only one form number. You must list all filed forms in separate lines on the Form Schedule tab, and enter form numbers correctly. Each form listed on the Form Schedule tab must have only one form number. A form retains the same form number throughout the review process. A form which has undergone any revision outside the review process is a new form. This means you may not file a revised version of a previously approved form using the same form number. If you are filing revised versions of previous year’s forms: You must file the revised forms on the Form Schedule tab with unique form numbers. When you list the revised form on the Form Schedule tab, you must populate the “Action” field with “Revised”. You will then be prompted to enter “Action Specific Data”. In the Action Specific Data field, you must enter the form number of the previous year’s form (the one you are replacing) and the SERFF Tracking Number under which the previous year’s form was filed. (See “Diagram: Filing Revised Versions of Previous Year’s Forms” below. See “Action” and “Action Specific Data” columns.) You must attach a strikeout/underline (redline) of the changes from the previous year’s forms on the Supporting Documentation tab.

Diagram. Filing Revised Versions of Previous Year’s Forms: You may not use Non-Administrative Variability to define product or plan design: Different products must be filed separately. Plans with different benefits are separate products. No benefits (such as adult dental or contraception) may be bracketed in Individual or Small Group plans. Different plans within each product may not be filed using any form of Non-Administrative variability or bracketing. Administrative Variability may be used in Individual or Small Group filings, including necessary Exchange and Off-Exchange eligibility language. Administrative Variability does not require a formal variability statement. Pediatric stand-alone dental plan (with Pediatric Dental EHB) for 2023 2024 plan year: Scope of Section by TOI in SERFF: H10I.001 or H10G.001 Submission Requirements: You must use, with no variations, one of the following naming conventions (as appropriate) in the SERFF Product Name field on the General Information tab: Individual - EHB Dental - Both Inside and Outside Exchange. Individual - EHB Dental - Exchange Only. Individual - EHB Dental - Outside Exchange Only. Small Group - EHB Dental - Both Inside and Outside Exchange. Small Group - EHB Dental - Exchange Only. Small Group - EHB Dental - Outside Exchange Only. In the Corresponding Filing Tracking Number field, list the SERFF Tracking Number(s) of the corresponding rate filing(s) (public and separate not-for-public rate filing, if requested). DO NOT file Large and Small Group products combined. 2023 2024 Cascade Care Standardized and Public Option Health Plans (RCW 43.71.095) Scope of Section by TOI in SERFF: H16I and HOrg02I This section applies to all Standardized (Cascade) and Public Option (Cascade Select) health plans to be offered through the Washington Health Benefit Exchange (WAHBE). Public Option Health Plans must use the Standardized Plan design. Standardized and Public Option Health Plans may only be marketed through the Exchange. Filing Instructions: Forms must be filed according to Section IV of these instructions, with the exception of: Standardized Health Plans: You must use the following naming convention in the Form Name field on the Form Schedule tab: “[Issuer Name] Cascade [Metal Level].” Public Option Health Plans: You must use the following naming convention in the Form Name field on the Form Schedule tab: “[Issuer Name] Cascade Select [Metal Level].” An issuer must contact the Exchange directly to discuss and receive approval from the Exchange to use additional identifying elements or plan marketing names in the naming conventions listed in a. and b. above. Approvals received from the Exchange must be attached to the Supporting Documentation tab. DO NOT submit Schedule of Benefits, or any other form, specific to cost-sharing alternatives, including the cost-sharing reduction (CSR) Silver Variant or Tribal plans. Cost-sharing alternative plan information is represented in the Binder’s Plan & Benefits Template only. Student Health Plans See Form Filings Speed-to-Market Guide, Section XI – Student Health Plans, for additional information regarding expediting review of Student Health Plans. Filing requirements: 20222023-2023 2024 school year student health plans filing submissions must be received by May 1918, 20222023. Forms must be filed separately but concurrently with the rates and network access reports. The network name must be clearly identified in the certificate of coverage/benefit booklet and match the network name filed with the OIC exactly (for example: “Your Provider Network is: ________________.”) Binders are not required for student health plans. “PPACA” field: Populate this field with “Non-Grandfathered Immed Mkt Reform.” More information on the PPACA field is available by clicking on the “What is PPACA” link directly below this field. “Include Exchange Intentions” field: Student health plans should be marked as “No” in this field. The Product Name must have the following naming conventions: “20222023-2023 2024 School Year Student Health Plan.” “Corresponding Filing Tracking Number” field: You must complete the “Corresponding Filing Tracking Number” field if there is a required corresponding filing (for example, for-public/not-for-public rate, etc.). (Note that this field can be changed via post-submission update if necessary.) A “Corresponding Filing Tracking Number” is the number for a filing that is required to be filed in relation to the current filing. There is no need to list filings other than rate filings (for example, it’s unnecessary to list all form filings sold to the same group, etc.) A corresponding filing tracking number must be a SERFF tracking number. It cannot be a state tracking number, company tracking number, or form number. If there are too many corresponding filing tracking numbers to be placed in the “Corresponding Filing Tracking Number” field (for example, a proprietary rate filing for a specific group that has multiple products), you may list the corresponding filing tracking numbers in a separate document attached on the Supporting Documentation tab and indicate this in the “Corresponding Filing Tracking Number” field. You may not use non-administrative variability or bracketing or variability to define product or plan design, including benefits or cost sharing amounts. Limited variability will be accepted for administrative purposes only, such as, but not limited to the following: signature blocks, school name, and street address. Limited variability used for administrative purposes only does not require a formal variability statement. You may attach supporting documentation for a specific form under the Supporting Documentation tab. You may not encrypt or otherwise electronically protect any document filed with OIC for review. We must be able to make a PDF copy of each of your forms. Forms translated from English to another language must be filed according to the requirements of WAC 000-00-000. In your initial submission, all forms that comprise your filing must be in final format and attached on the Form Schedule tab. You must list all filed forms in separate lines on the Form Schedule tab, tab and enter form numbers correctly. Each form listed on the Form Schedule tab must have only one form number. You must list all filed forms in separate lines on the Form Schedule tab, and enter form numbers correctlyaccurately. Each form listed on the Form Schedule tab must have only one form number. A form retains the same form number throughout the review process. A form which has undergone any revision outside the review process is a new form. This means you may not file a revised version of a previously approved form using the same form number. If you are filing revised versions of previous year’s forms: You must file the revised forms on the Form Schedule tab with unique form numbers. When you list the revised form on the Form Schedule tab, you must populate the “Action” field with “Revised”. You will then be prompted to enter “Action Specific Data”. In the Action Specific Data field, you must enter the form number of the previous year’s form (the one you are replacing) and the SERFF Tracking Number under which the previous year’s form was filed. (See “Diagram: Filing Revised Versions of Previous Year’s Forms” below. See “Action” and “Action Specific Data” columns.) You must attach a strikeout/underline (redline) of the changes from the previous year’s forms on the Supporting Documentation tab.

Diagram. Filing Revised Versions of Previous Year’s Forms: You may not use Non-Administrative Variability to define product or plan design: Different products must be filed separately. Plans with different benefits are separate products. No benefits (such as adult dental or contraception) may be bracketed in Individual or Small Group plans. Different plans within each product may not be filed using any form of Non-Administrative variability or bracketing. Administrative Variability may be used in Individual or Small Group filings, including necessary Exchange and Off-Exchange eligibility language. Administrative Variability does not require a formal variability statement. Pediatric stand-alone dental plan (with Pediatric Dental EHB) for 2023 2025 plan year: Scope of Section by TOI in SERFF: H10I.001 or H10G.001 Submission Requirements: You must use, with no variations, one of the following naming conventions (as appropriate) in the SERFF Product Name field on the General Information tab: Individual - EHB Dental - Both Inside and Outside Exchange. Individual - EHB Dental - Exchange Only. Individual - EHB Dental - Outside Exchange Only. Small Group - EHB Dental - Both Inside and Outside Exchange. Small Group - EHB Dental - Exchange Only. Small Group - EHB Dental - Outside Exchange Only. In the Corresponding Filing Tracking Number field, list the SERFF Tracking Number(s) of the corresponding rate filing(s) (public and separate not-for-public rate filing, if requested). DO NOT file Large and Small Group products combined. 2023 2025 Cascade Care Standardized and Public Option Health Plans (RCW 43.71.095) Scope of Section by TOI in SERFF: H16I and HOrg02I This section applies to all Standardized (Cascade) and Public Option (Cascade Select) health plans to be offered through the Washington Health Benefit Exchange (WAHBE). Public Option Health Plans must use the Standardized Plan design. Standardized and Public Option Health Plans may only be marketed through the Exchange. Filing Instructions: Forms must be filed according to Section IV of these instructions, with the exception of: Standardized Health Plans: You must use the following naming convention in the Form Name field on the Form Schedule tab: “[Issuer Name] Cascade [Metal Level].” Public Option Health Plans: You must use the following naming convention in the Form Name field on the Form Schedule tab: “[Issuer Name] Cascade Select [Metal Level].” An issuer must contact the Exchange directly to discuss and receive approval from the Exchange to use additional identifying elements or plan marketing names in the naming conventions listed in a. and b. above. Approvals received from the Exchange must be attached to the Supporting Documentation tab. DO NOT submit Schedule of Benefits, or any other form, specific to cost-sharing alternatives, including the cost-sharing reduction (CSR) Silver Variant or Tribal plans. Cost-sharing alternative plan information is represented in the Binder’s Plan & Benefits Template only. Student Health Plans See Form Filings Speed-to-Market Guide, Section XI – Student Health Plans, for additional information regarding expediting review of Student Health Plans. Filing requirements: 20222024-2023 2025 school year student health plans filing submissions must be received by May 1916, 20222024. Forms must be filed separately but concurrently with the rates and network access reports. The network name must be clearly identified in the certificate of coverage/benefit booklet and match the network name filed with the OIC exactly (for example: “Your Provider Network is: ________________.”) Binders are not required for student health plans. “PPACA” field: Populate this field with “Non-Grandfathered Immed Mkt Reform.” More information on the PPACA field is available by clicking on the “What is PPACA” link directly below this field. “Include Exchange Intentions” field: Student health plans should be marked as “No” in this field. The Product Name must have the following naming conventions: “20222024-2023 2025 School Year Student Health Plan.” “Corresponding Filing Tracking Number” field: You must complete the “Corresponding Filing Tracking Number” field if there is a required corresponding filing (for example, for-public/not-for-public rate, etc.). (Note that this field can be changed via post-submission update if necessary.) A “Corresponding Filing Tracking Number” is the number for a filing that is required to be filed in relation to the current filing. There is no need to list filings other than rate filings (for example, it’s unnecessary to list all form filings sold to the same group, etc.) A corresponding filing tracking number must be a SERFF tracking number. It cannot be a state tracking number, company tracking number, or form number. If there are too many corresponding filing tracking numbers to be placed in the “Corresponding Filing Tracking Number” field (for example, a proprietary rate filing for a specific group that has multiple products), you may list the corresponding filing tracking numbers in a separate document attached on the Supporting Documentation tab and indicate this in the “Corresponding Filing Tracking Number” field. You may not use non-administrative variability or bracketing or variability to define product or plan design, including benefits or cost sharing amounts. Limited variability will be accepted for administrative purposes only, such as, but not limited to the following: signature blocks, school name, and street address. Limited variability used for administrative purposes only does not require a formal variability statement. You may attach supporting documentation for a specific form under the Supporting Documentation tab. You may not encrypt or otherwise electronically protect any document filed with OIC for review. We must be able to make a PDF copy of each of your forms. Forms translated from English to another language must be filed according to the requirements of WAC 000-00-000. In your initial submission, all forms that comprise your filing must be in final format and attached on the Form Schedule tab. You must list all filed forms in separate lines on the Form Schedule tab, tab and enter form numbers correctly. Each form listed on the Form Schedule tab must have only one form number. You must list all filed forms in separate lines on the Form Schedule tab, and enter form numbers correctlyaccurately. Each form listed on the Form Schedule tab must have only one form number. A form retains the same form number throughout the review process. A form which has undergone any revision outside the review process is a new form. This means you may not file a revised version of a previously approved form using the same form number. If you are filing revised versions of previous year’s forms: You must file the revised forms on the Form Schedule tab with unique form numbers. When you list the revised form on the Form Schedule tab, you must populate the “Action” field with “Revised”. You will then be prompted to enter “Action Specific Data”. In the Action Specific Data field, you must enter the form number of the previous year’s form (the one you are replacing) and the SERFF Tracking Number under which the previous year’s form was filed. (See “Diagram: Filing Revised Versions of Previous Year’s Forms” below. See “Action” and “Action Specific Data” columns.) You must attach a strikeout/underline (redline) of the changes from the previous year’s forms on the Supporting Documentation tab. The redline must match the clean copy of the form attached to the Form Schedule tab exactly. Please note that at the Analyst discretion, you may be asked to attach a certification, signed by a person with authority to make a certification on behalf of the company, to the Supporting Documentation tab verifying that only those modifications indicated on the redline were made.