Department of Health and Human Services - GPO

1 Vol. 80 Friday, No. 39 February 27, 2015 Part II Department of Health and Human Services 45 CFR Parts 144, 147, 153, et al. Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016; Final Rule VerDate Sep<11>2014 17:26 Feb 26, 2015 Jkt 235001 PO 00000 Frm 00001 Fmt 4717 Sfmt 4717 E:\FR\FM\ 27 FER2tkelley on DSK3 SPTVN1 PROD with RULES210750 Federal Register/ Vol. 80, No. 39 / Friday, February 27, 2015 / Rules and Regulations Department OF Health AND Human Services 45 CFR Parts 144, 147, 153, 154, 155, 156 and 158 [CMS 9944 F] RIN 0938 AS19 Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

2 ACTION: Final rule. SUMMARY: This final rule sets forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also finalizes additional standards for the individual market annual open enrollment period for the 2016 benefit year, essential Health benefits, qualified Health plans, network adequacy, quality improvement strategies, the Small Business Health Options Program, guaranteed availability, guaranteed renewability, minimum essential coverage, the rate review program, the medical loss ratio program, and other related topics. DATES: These regulations are effective on April 28, 2015 except the amendments to , (d)(1)(ii), and are effective on January 1, 2016.

3 FOR FURTHER INFORMATION CONTACT:For general information: Jeff Wu, (301) 492 4305. For matters related to guaranteed availability, guaranteed renewability, rate review, or the applicability of Title I of the Affordable Care Act in the Territories: Jacob Ackerman, (301) 492 4179. For matters related to risk adjustment or the methodology for determining the reinsurance contribution rate and payment parameters: Kelly Horney, (410) 786 0558. For matters related to reinsurance generally, distributed data collection good faith compliance policy, or administrative appeals: Adrianne Glasgow, (410) 786 0686. For matters related to the definition of common ownership for purposes of reinsurance contributions: Adam Shaw, (410) 786 1019.

4 For matters related to risk corridors: Jaya Ghildiyal, (301) 492 5149. For matters related to essential Health benefits, network adequacy, essential community providers, or other standards for QHP issuers: Leigha Basini, (301) 492 4380. For matters related to the qualified Health plan good faith compliance policy: Cindy Yen, (301) 492 5142. For matters related to the Small Business Health Options Program: Christelle Jang, (410) 786 8438. For matters related to the Federally- facilitated Exchange user fee or minimum value: Krutika Amin, (301) 492 5153. For matters related to cost-sharing reductions or the premium adjustment percentage: Pat Meisol, (410) 786 1917. For matters related to re-enrollment, open enrollment periods, or exemptions from the individual shared responsibility payment: Christine Hammer, (301) 492 4431.

5 For matters related to special enrollment periods: Rachel Arguello, (301) 492 4263. For matters related to minimum essential coverage: Cam Moultrie Clemmons, (206) 615 2338. For matters related to quality improvement strategies: Marsha Smith, (410) 786 6614. For matters related to the medical loss ratio program: Julie McCune, (301) 492 4196. For matters related to meaningful access to QHP information, consumer assistance tools and programs of an Exchange, or cost-sharing reduction notices: Tricia Beckmann, (301) 492 4328. SUPPLEMENTARY INFORMATION: Table of Contents I. Executive Summary II. Background A. Legislative and Regulatory Overview B. Stakeholder Consultation and Input III. Provisions of the Final Regulations and Analysis and Responses to Public Comments A.

6 Part 144 Requirements Relating to Health Insurance Coverage 1. Definitions ( ) a. Plan b. State B. Part 147 Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets 1. Guaranteed Availability of Coverage ( ) 2. Guaranteed Renewability of Coverage ( ) C. Part 153 Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment Under the Affordable Care Act 1. Provisions for the State Notice of Benefit and Payment Parameters ( ) 2. Provisions and Parameters for the Permanent Risk Adjustment Program a. Risk Adjustment User Fee ( (f)) b. Overview of the HHS Risk Adjustment Model ( ) c. Proposed Updates to Risk Adjustment Model ( ) d. List of Factors To Be Employed in the Model ( ) e.

7 Cost-Sharing Reductions Adjustments ( ) f. Model Performance Statistics ( ) g. Overview of the Payment Transfer Formula ( ) h. HHS Risk Adjustment Methodology Considerations ( ) i. State-Submitted Alternate Risk Adjustment Methodology ( ) 3. Provisions and Parameters for the Transitional Reinsurance Program a. Common Ownership Clarification b. Reinsurance Contributing Entities and Minimum Value c. Self-Insured Expatriate Plans ( (a)(1)(iii)) d. Determination of Debt ( (c)) e. Reinsurance Contribution Submission Process f. Consistency in Counting Methods for Health Insurance Issuers ( (d)) g. Snapshot Count and Snapshot Factor Counting Methods ( (d)(2) and (e)(2)) h. Uniform Reinsurance Contribution Rate for 2016 i.

8 Uniform Reinsurance Payment Parameters for 2016 j. Uniform Reinsurance Payment Parameters for 2015 k. Deducting Cost-Sharing Reduction Amounts From Reinsurance Payments 4. Provisions for the Temporary Risk Corridors Program a. Application of the Transitional Policy Adjustment in Early Renewal States b. Risk Corridors Payments for 2016 5. Distributed Data Collection for the HHS- Operated Risk Adjustment and Reinsurance Programs a. Good Faith Safe Harbor ( (a)) b. Default Risk Adjustment Charge ( (b)) c. Information Sharing ( (c)) D. Part 154 Health Insurance Issuer Rate Increases: Disclosure and Review Requirements 1. General Provisions a. Definitions ( ) 2. Disclosure and Review Provisions a. Rate Increases Subject to Review ( ) b.

9 Submission of Rate Filing Justification ( ) c. Timing of Providing the Rate Filing Justification ( ) d. CMS s Determinations of Effective Rate Review Programs ( ) E. Part 155 Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act 1. General Provisions a. Definitions ( ) 2. General Functions of an Exchange a. Consumer Assistance Tools and Programs of an Exchange ( ) b. Standards Applicable to Navigators and Non-Navigator Assistance Personnel Carrying Out Consumer Assistance Functions Under (d) and (e) and in a Federally-Facilitated Exchange and to Non-Navigator VerDate Sep<11>2014 17:26 Feb 26, 2015 Jkt 235001 PO 00000 Frm 00002 Fmt 4701 Sfmt 4700 E:\FR\FM\ 27 FER2tkelley on DSK3 SPTVN1 PROD with RULES210751 Federal Register/ Vol.

10 80, No. 39 / Friday, February 27, 2015 / Rules and Regulations Assistance Personnel Funded Through an Exchange Establishment Grant ( ) c. Ability of States To Permit Agents and Brokers To Assist Qualified Individuals, Qualified Employers, or Qualified Employees Enrolling in QHPs ( ) d. Standards for HHS-Approved Vendors of Federally-Facilitated Exchange Training for Agents and Brokers ( ) 3. Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability Programs a. Annual Eligibility Redetermination ( ) 4. Exchange Functions in the Individual Market: Enrollment in Qualified Health Plans a. Enrollment of Qualified Individuals Into QHPs ( ) b.