The Compliance Certificate:
its purpose, its content, its scope, its signing
The primary objective of risk pooling is to ensure accessibility of insured to insurance coverage, despite the risk of high costs of certain drugs. The process keeps the risks within the industry and distributes costs evenly throughout the industry in such a way that the total amount claimed equals the total amount paid in compensation. The success of this system relies on the frank collaboration of all participants and consistent application of rules to ensure fairness among participants.
The Corporation oversees the sound management of the system of risk pooling (sharing) supported by the industry. An important part of this work is to obtain the data in a uniform manner from the industry for the pooling process.
In order to ensure the validity of the information obtained, the Corporation requires all participants (insurers, third-party payers or benefit plan administrators) to complete and file a certificate of compliance.
This certificate allows the Corporation to ensure compliance with the legal and regulatory framework in force as well as the rules issued by the Corporation. Indeed, each signatory certifies that all the information presented for pooling purposes is in compliance.
Thus, each signatory confirms, on behalf of the participant, that the participant’s practice meets the requirements of risk pooling and, in particular, that the size of the groups submitted is established according to the principles outlined in the bulletin QDIPCinfo- Terms of application – Group size published in October 2019.
The Compliance Certificate establishes the basis on which the information must be provided for the volume of exposure and claims, and the related guidelines. It also includes a compliance commitment. The certificate indicates that all data transmitted complies with the requirements of the pooling process in effect for 2019, including the following statements:
Volume of exposure
- All groups of fewer than 6,000 certificates which include at least one certificate in Quebec have been submitted;
- All groups, including those with more than 6,000 certificates, which include at least one certificate in Quebec, have been submitted. The name, contract number, size of group and the type of group (employer-employees, multi employer, association of persons) have been disclosed for groups with more than 6,000 certificates;
- All groups submitted for pooling were established in compliance with the requirements of the applicable laws and were still compliant on December 31, 2020;
- For all “groups of one”, the information justifying exemption from coverage of other employee(s) is on file. A group of one is a group with several employees but having only one Quebec certificate subject to pooling (i.e.: exemption due to spousal coverage, the presence of employees outside of Quebec, …);
- The size of the groups was determined in accordance with the rules and interpretations set out in QDIPCinfo – Terms of application – Group Size, published in October 2019. However, participants have been informed of a transition period and that they must comply as quickly as possible, on or before December 31, 2021. The Appendix A has been completed for all groups that are not compliant with the rules and interpretations set out in the QDIPCinfo published in October 2019;
- Groups submitted cover members who have a direct link with the policyholder in accordance with the eligibility criteria set out in the Quebec Prescription Drug insurance Act, notably in sections 15.1, 16, 42.1 and 42.2;
- All multi-employer groups that have been reported as one group (regardless of the size) are listed in Appendix B.
- Groups submitted have not been grouped or split in order to derive a benefit from pooling.
Pledge of compliance
The certificate includes the following pledge of compliance:
(…) I declare that, to the best of my knowledge, all contracts that were in effect during the year 2020 have been managed in accordance with the rules of the Corporation;
The information provided as of December 31, 2020 is complete, accurate, verifiable and, if applicable, takes into account the comments received during any previous audit;
The information provided includes all contracts managed by a third party (e.g. by a TPA), and the company remains liable to the Corporation for the compliance data compiled by a third party;
I am authorized to sign on behalf of the participating company named above, which is bound by this declaration.”
- All claims that are eligible for pooling, from groups of fewer than 6,000 certificates have been submitted;
- Covered and eligible drugs are those of the private plan;
- For each certificate, the total eligible amount, the total amount reimbursed, and the status of the certificate with or without dependants for which a payment was issued in 2020 have been reported;
- Claims submitted reflect actual net costs and reflect all rebates and discounts received or receivable;
- Claims reimbursed as second payer are included;
- The additional information requested, in cases where the contract number has not been reported as risk exposure, has been provided;
- Only drugs with an eligible DIN or NPN have been included in the submitted data.
The company I represent has adhered to the following guiding principles:
- i)Activities and practices used in managing plans must not allow for any manipulation with a goal of avoiding or profiting from pooling;
- The definition of a group on which the pooling process is based, is that used in the industry in accordance with the provisions and regulations of Quebec’s Act respecting insurance and Act respecting prescription drug insurance;
- Group size must be established using the number of certificates with drug insurance (i.e. excluding those certificates exempted from this coverage);
- The size of a group terminated at the end of 2020 will be determined by the pooling Manager using the average number of (Canadian) certificates at the beginning and end of the contract’s exposure period during the year.
To ensure consistent application of the rules and to limit the risks surrounding the delivery of data for the pooling process, the Corporation has a policy that allows it to perform data audits at the offices of the participants themselves.
The compliance certificate is an important control measure because once signed, it commits the responsibility of each participant.
The compliance certificate also helps preserve the industry’s privilege of setting its own rules for pooling drug insurance risks.
A compliance certificate that accurately reflects the operations of a participant not only allows the Corporation to fulfill its mandate fairly for all participants, but also to justify the amounts received or granted in the compensation process.
In addition, the Corporation takes all the necessary actions to protect the confidentiality of the information received.
Delegation of Management
Administrative or commercial management is sometimes delegated to third parties (TPAs, actuaries, brokers, or others), but the ultimate responsibility of the participant towards the Corporation cannot be transferred.
The participant must always be in possession of the necessary information to justify its own data declaration to the pooling process and must always have complete knowledge of the data transmitted by its subcontractors. It ensures that all data is delivered without errors, duplications, nor omissions.
Due to the important information contained in the Compliance Certificate, only a person with the authority to represent the participant can sign such a document.
This may be the authorized signatory of a company or one of its directors. This person must be able to explain the information provided for the pooling process and represent the company as a debtor or creditor at the Compensation Table.
Industry collaboration, including the Compliance Certificate, is critical. It is up to each participant in the process to properly complete the certificate and to contact the Corporation for any questions regarding its content.