The adjustment amount for outliers is the distance between issuer i' s Group Failure Rate GFRiG and the weighted mean m(GFRG), calculated as: Then FlagiG = “outlier” and AdjustmentiG = GFRiG − m(GFRG), Then FlagiG = “not outlier” and AdjustmentiG = 0. This includes maintaining the 14 percent administrative cost reduction to the statewide average premium for the 2021 benefit year. Although the amount of the reduction in the maximum annual limitation on cost sharing is specified in section 1402(c)(1)(A) of the PPACA, section 1402(c)(1)(B)(ii) of the PPACA states that the Secretary may adjust the cost-sharing limits to ensure that the resulting limits do not cause the AV of the health plans to exceed the levels specified in section 1402(c)(1)(B)(i) of the PPACA (that is, 73 percent, 87 percent, or 94 percent, depending on the income of the enrollee). This final rule implements standards for programs that will have numerous effects, including providing consumers with access to affordable health insurance coverage, reducing the impact of adverse selection, and stabilizing premiums in the individual and small group health insurance markets and in an Exchange. In the 2019 Payment Notice, to avoid adjusting all issuers' risk adjustment transfers for expected variation and error, we finalized a new methodology to evaluate material statistical deviation in data validation failure rates beginning with 2017 benefit year RADV. For the 2021 benefit year, HHS received a request to reduce risk adjustment transfers for the Alabama small group market by 50 percent. [167] In subsequent years, if there are changes in benefits, we estimate that a compensation and benefits manager will need 0.5 hours (at $127.74 per hour) and a lawyer will need 0.25 hours (at $138.68 per hour) to update the notice. Reactive and Unspecified Psychosis, Delusional Disorders, • Add 2 new HCCs for alcohol use disorders for all models. Another commenter supported exempting new issuers from risk adjustment, applying a creditability approach to risk adjustment participation or placing an upper bound on risk adjustment transfer charges. We also believe that the benefit of simplifying plan category limitation rules and ensuring that these rules work as intended by applying the same limitations to enrolled dependents that apply to non-dependents will outweigh costs associated with implementation. This commenter asked that HHS change the word “confirm” to “verify” in § 156.265(g)(1). After reviewing the public comments, we are finalizing this provision as proposed. 14. We note that an issuer or group health plan that elects to credit direct drug manufacturer support amounts toward the minimum deductible of an HDHP could disqualify an individual from making HSA contributions, pursuant to Q&A-9 of Notice 2004-50. Therefore, we estimate that the average per-Exchange cost of implementing sampling that resembles the approach taken by the Exchanges using the Federal platform would have been approximately $4.5 million for State Exchanges that operate their own eligibility and enrollment platform, for a total cost of $58.5 million for the 13 State Exchanges that operate their own eligibility and enrollment platform (operating in 12 States and the District of Columbia). However, as also noted earlier in the preamble, we intend to continue the collaborative process we have cultivated with states up to this point, and to provide non-reporting states with an opportunity to review our identifications prior to releasing the annual reports on the CMS website for public viewing in an effort to mitigate the potential for disagreement between the state and HHS. In all models, HCC 122 would be relabeled to “Coma/Brain Compression, Anoxic Damage” to account for the ongoing inclusion of coma codes that may be associated with a traumatic injury. This final rule contains information collection requirements (ICRs) that are subject to review by OMB. Response: Here, we clarify that the proposal would not create a new special enrollment period or incorporate additional flexibility into existing plan category limitations rules; in fact, it clarifies that these limitations apply to Exchange enrollees who are dependents in the same way that they apply to Start Printed Page 29207Exchange enrollees who are not dependents. job! [179] We estimate that the total cost for HHS to Start Printed Page 29249operate the risk adjustment program on behalf of states and the District of Columbia for 2021 will be approximately $60 million, and the risk adjustment user fee will be $0.25 PMPM. Table 65 in this final rule presents the mean hourly wage, the cost of fringe benefits and overhead, and the adjusted hourly wage. If all failure rates in a state market risk pool do not materially deviate from the national mean failure rates, we do not apply any adjustments to issuers' risk scores for that benefit year in the respective state market risk pool.[82]. https://www.sba.gov/document/support--table-size-standards. If regulations impose administrative costs on private entities, such as the time needed to read and interpret this final rule, we should estimate the cost associated with regulatory review. We believe that a small number of non-Federal government jurisdictions with a population of less than 50,000 will offer employees an excepted benefit HRA, and therefore, will be subject to the proposed notice requirement in part 146. In the 2019 Payment Notice,[126] We also noted that selecting a reduction for the maximum annual limitation on cost sharing that is less than the reduction specified in the statute would not reduce the benefit afforded to enrollees in the aggregate because QHP issuers are required to further reduce their annual limitation on cost sharing, or reduce other types of cost sharing, if the required reduction does not cause the AV of the QHP to meet the specified level. Regardless, we believe that this change will not have a negative impact on the individual market risk pool, because most applicable enrollees will seek to change coverage based on financial rather than health needs. Therefore we believe it is appropriate to apply the same plan category limitations to all enrollees, whether or not they are dependents. We anticipate that this will benefit applicable enrollees and dependents by providing them with additional flexibility to change to a plan better suited to their needs based on changes to their premiums and/or cost-sharing requirements. Of these commenters, one asked that State Exchanges have the option not to implement plan category limitations requirements at all. Commenters who supported the entire proposal agreed the reporting should occur annually. Additionally, because billing is tied to effective dates, transitioning to these more expedited effective dates in the Exchanges using the Federal platform will simplify issuer billing practices. The deadline for state submission of EHB-benchmark plan changes and to notify HHS that the state will allow between-category benefit substitution for the 2023 plan year is May 7, 2021. We do not anticipate these requirements will add any new burden on non-reporting states as they will be relying on HHS to make these determinations and fill out these templates for them. Response: As these comments do not pertain to the proposals, we will take them into consideration for future rulemaking. Accordingly, we proposed to make updates to binder payment deadlines in § 155.400(e)(1)(ii) to ensure that special enrollment periods using effective dates under revised § 155.420(b)(3) would also be subject to the same binder payment rules as other special enrollment periods that are effective the first of the month following plan selection. These provisions were written under the assumption that issuers would generally be able to provide these confirmations or disputes automatically to HHS. Consistent with these regulations, Exchanges must prominently display on their websites, in accordance with § 155.205(b)(1)(iv) and (v), quality rating information assigned for each QHP [117] [141] Using the 2021 premium adjustment percentage finalized in this rule, the excess of the rate of premium growth over the rate of income growth for 2013 to 2020 is 1.3542376277 ÷ 1.3094029651, or 1.0342405385. Under current rules, if a consumer's enrollment is delayed until after the verification of the consumer's eligibility for a special enrollment period, and the assigned effective date would require the consumer to pay 2 or more months of retroactive premium to effectuate coverage or avoid cancellation, the consumer has the option to choose a coverage effective date that is no more than 1 month later than had previously been assigned. Response: We did not propose to make changes to the high-cost risk pool adjustment or parameters in the proposed rule. Updating our regulations to require issuers to send termination notices to enrollees for all termination events, regardless of who initiated the termination, will help streamline issuer operations and reduce confusion. The original version of § 156.270 required a termination notice when an enrollee's coverage was terminated “for any reason,” [160] Based on HHS's experience with the Exchanges issuing such notices to employers, the Exchange does not have the capability to distinguish between employers that are or are not subject to the ESRP. We believe that setting this cut-off date at least 60 days prior to the submission deadline allows a state sufficient time to analyze its state benefit requirements imposed, amended, or repealed through state action taken by that date and prepare the required documents we are proposing that states submit to HHS. We are finalizing these policies as proposed, but delaying the effective date until January 2022 to allow the sufficient time to implement these changes. One commenter noted their appreciation for the proposal but argued the reporting requirement should be every two years at most to reduce administrative burden and unnecessary costs, given that the process for enacting state mandates is often a long one. Therefore, we reminded states that, as we stated in the example methodology guidance,[135] As explained in the proposed rule, since the implementation of § 155.420(a)(4) in states served by the Federal platform, HHS has received questions and concerns about this issue from Navigators, agents and brokers, and other enrollment assisters. The provision to remove the regulations at part 149 of title 45 governing the ERRP will not have any direct regulatory impact since the ERRP sunset as of January 1, 2014. For example, the current rules do not explicitly address what limitations apply when a mother loses her self-only employer-sponsored coverage, thereby gaining eligibility for a special enrollment period for loss of MEC, and seeks to be added as an enrollee to the Exchange coverage in which her two young children are currently enrolled. Lastly, we believe that maintaining the same threshold and coinsurance rate from year-to-year will help promote stability and predictability for issuers. Commenters supported the approach outlined in the proposed rule as it would allow QHP issuers to maintain flexibility while incrementally introducing value-based insurance design options for Exchange enrollees. Commenters also agreed with HHS that an employer-sponsored coverage verification approach should provide State Exchanges with flexibility and more opportunities to use Start Printed Page 29200verification processes that are evidence-based, while imposing the least amount of burden on consumers, states, employers, and taxpayers. However, we are aware that 4 State Exchanges that operate their own eligibility and enrollment platform have already incurred costs to implement sampling and estimate that they have incurred one-time costs of approximately $4.5 million per Exchange with a total of $18 million and will only experience savings related to recurring costs. We also considered and solicited comment on an alternate proposal that would lower the SBE-FP user fee rate below the 2020 benefit year level to a level that would reduce the user fee burden on consumers, while still covering the costs of the special benefits HHS provides to SBE-FP issuers. HHS will provide the template(s) to states that states are required to use for reporting the required information proposed in § 156.111(f)(1) through (6). For issuers who elect to include these amounts towards a consumer's annual limitation on cost sharing, the value of direct drug manufacturer support would be considered part of the overall charges incurred by the enrollee. This rule finalizes standards related to the risk adjustment program for the 2021 benefit year, clarifications and improvements to the RADV program, as well as certain modifications that will promote transparency, innovation in the private sector, reduce burden on stakeholders, and improve program integrity. In addition, sections 1311(c)(3) and 1311(c)(4) direct the Secretary of HHS to develop a rating system and a system to assess enrollee satisfaction. In the Exchange and Insurance Market Standards for 2015 and Beyond Final Rule [115] Another commenter stated that the 2019 Payment Notice did not sufficiently emphasize that a state could not exceed the generosity standard. One commenter encouraged HHS to continue working with issuers and consumers relating to display of QRS information in a meaningful manner and to be transparent in disclosing information on the use of QRS information during plan selection and enrollment. [75] We estimate that sponsors will provide printed copies of these notices to approximately 193,715 eligible participants annually. To ease burden, one commenter recommended that HHS leverage the existing reporting related to EHB rather than creating a new, duplicative report. We proposed to amend § 155.330(e)(2)(i)(D) to provide that Exchanges need not redetermine eligibility for APTC or CSRs for enrollees who (1) are found to be dually enrolled in QHP coverage and MEC consisting of Medicare, Medicaid/CHIP, or, if applicable, the Basic Health Program (BHP); (2) have not responded to the Exchange notice to provide updated information within 30-days; and (3) have previously provided written consent for the Exchange to end their QHP coverage via PDM in the event of dual enrollment or eligibility. “A Comparative Analysis of Claims-Based Tools for Health Risk Assessment.” Society of Actuaries. HHS prefers for states to provide the required information on their state-required benefits to support HHS's efforts to determine whether it is paying APTC correctly. See 42 U.S.C. Sd (GFRG is the standard deviation of GFRiG of all issuers for the HCC group G. If an issuer's failure rate for an HCC group falls outside the confidence interval for the weighted mean failure rate for the HCC group, the failure rate for the issuer's HCCs in that group is considered an outlier. One commenter requested that, to support the administration's goals of state flexibility, HHS instead allow states to submit state mandate information in a form and manner determined by the state. That is, whether a benefit mandated by state action could be considered EHB would continue to depend on when the state enacted the mandate (unless the benefit mandated was for the purposes of compliance with Federal requirements). Furthermore, per § 155.310(i), the IRS currently sends letters to employers, known as ”226-J letters,” to certify to an employer that one or more employees has enrolled for one or more months during a year in a QHP with APTC in order to satisfy the requirement under section 4980H of the Code. a collection of key value pairs, where the values are static or selected from the Alternatively, you can adjust your Lower sample sizes are more likely to lead to non-normal distributions of sample summary statistics—for example, the means of multiple samples—if the distribution of the underlying population is non-normal. 167. The proposed reductions in the maximum annual limitation on cost sharing must adequately account for unique plan designs that may not be captured by our three model QHPs. Although there is still some uncertainty regarding the net effect on premiums, we anticipate that the provisions of this final rule will help further HHS's goal of ensuring that all consumers have access to quality and affordable health care and are able to make informed choices, that the insurance market offers choices, and that states have more control and flexibility over the operation and establishment of Exchanges. Instead, we proposed to amend § 156.1210(b) to require an annual confirmation from issuers that the amounts identified in the most recent payment and collections report for the coverage year accurately reflect applicable payments owed by the issuer to the Federal Government and the payments owed to the issuer by the Federal Government, or that the issuer has disputed any identified inaccuracies, after the end of each payment year, in a form and manner specified by HHS. See the Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond; Final Rule; (May 27, 2014), 79 FR 30240 at 30310, available at https://www.gpo.gov/fdsys/pkg/FR-2014-05-27/pdf/2014-11657.pdf. Many commenters questioned whether HHS has any available enforcement authority to actually require states to defray the cost of a state benefit requirements in such situations of disagreement between the state and HHS. While we decided against proposing any changes to the regulations at this time, we invited comments on this topic. This additional time will also allow us to further consider the suggested alternative definition for “price concession”. We anticipate that the notices will be approximately 1-page long, and the cost of materials and printing will be $0.05 per notice. Previously, section 155.420(b)(5) provided that if a consumer's enrollment is delayed until after the verification of the consumer's eligibility for a special enrollment period, and the assigned effective date would require the consumer to pay 2 or more months of retroactive premium to effectuate coverage or avoid cancellation, the consumer has the option to choose a coverage effective date that is no more than 1 month later than had previously been assigned. This represents an approximately 4.9 percent increase above the 2020 parameters of $8,150 for self-only coverage and $16,300 for other than self-only coverage. We proposed maintaining the FFE user fee for all participating FFE issuers at 3.0 percent of total monthly premiums. The FPC is determined by the equation FPC = (N − n_original/N, where N is the population size. We also agree that State Exchanges and other stakeholders should be provided opportunities to give input on potential future changes to the display of quality rating information. Within 90 calendar days of the date of a payment and collections report from HHS, the issuer must, in a form and manner specified by HHS describe to HHS any inaccuracies it identifies in the report. HHS believes that this policy will likely have minimal impact on the individual market risk pool because most applicable enrollees will be seeking to change coverage based on changes to their financial circumstances rather than ongoing or emerging health needs. We note that for 2021, as described in § 156.135(d), states are permitted to submit for HHS approval state-specific datasets for use as the standard population to calculate AV. However, the availability of a coupon or other direct support may cause physicians and enrollees to choose an expensive brand-name drug when a less expensive and equally effective generic or other alternative is available. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. These include subdividing the RADV process so that the individual and small group markets are each assessed separately; changing the materiality threshold criteria to a percentage of statewide premiums; using the current method for determining outliers, but basing adjustments on divergence from a state mean rather than a national mean; and applying additional scrutiny when issuers' supplemental data is dominated by additional diagnoses rather than modified or deleted diagnoses. Based on estimated costs, enrollment (including changes in FFE enrollment resulting from anticipated establishment of State Exchanges or SBE-FPs in certain states in which FFEs currently are operating), and premiums for the 2021 plan year, we solicited comment on two alternative proposals. Response: We agree with commenters that the Medicare PDM process is an important tool for Exchange program integrity. Under these changes, State Exchanges may retain their current effective date rules or implement faster ones without needing to demonstrate issuer concurrence. [72], As finalized in the 2020 Payment Notice, if the state requests that HHS not make publicly available certain supporting evidence and analysis because it contains trade secrets or confidential commercial or financial information within the meaning of the Freedom of Information Act (FOIA) regulations at 45 CFR 5.31(d), HHS will make available on the CMS website only the supporting evidence submitted by the state that is not a trade secret or confidential commercial or financial information by posting a redacted version of the state's supporting evidence.[73]. In addition, recognizing these challenges exist, we have taken steps to provide assistance to issuers with this process. Additionally, we are amending § 158.150(b)(2)(iv)(A)(5) to explicitly allow issuers in the individual market to include the cost of certain wellness incentives as QIA in the MLR calculation. Exchange Enrollees Newly Ineligible for CSRs, 8. We also considered revising § 155.170 to make HHS the entity responsible for identifying which state-required benefits are in addition to EHB in every state such that HHS would always identify which mandates require defrayal, but the QHP issuers would still be responsible for quantifying the costs for these additional mandates and reporting them to the state, at which point the state would be expected to make payments directly to the enrollee or the QHP issuer. The average annual burden over 3 years will be 496 hours with an equivalent annual cost of $65,109, and an average annual total cost of $69,565. Such a system might also present adverse selection concerns. The full classification includes both payment and non-payment HCCs. and one category of MEC is individual health insurance coverage, the HRA rule provides that individuals who are newly provided a QSEHRA also qualify for the new special enrollment period. Commenters also requested that HHS clarify the process for when HHS reviews a state's annual report, or makes the determination for a non-reporting state, and the state disagrees with HHS or otherwise refuses to comply with HHS's determination and does not defray the cost of the state benefit requirement that HHS believes is in addition to EHB. Many other commenters echoed the request that the annual reporting and defrayal requirements be made only on a prospective basis. The issuer provides demographic, enrollment, and medical record documentation for a sample of enrollees selected by HHS to the issuer's initial validation auditor for data validation. When consumers are relieved of copayment obligations, manufacturers are relieved of a market constraint on drug prices which can distort the market and the true cost of drugs. While the majority of commenters on this proposal expressed opposition, most of these commenters cited concerns about wellness programs themselves, such as concerns about their effectiveness and potential to discriminate, rather than concerns regarding the proposed amendment to the MLR rules. See Revenue Procedure 2019-29, 2019-32 IRB 620. https://www.irs.gov/pub/irs-drop/rp-19-29.pdf. Annually, HHS and CMS also publish detailed information on Federal Exchange Activities and budget request estimates, Start Printed Page 29218including expected Exchange user fee eligible costs.[122]. We solicited comment on the impacts of the proposal. Finally, § 155.420(a)(4)(iii)(A) requires that if an enrollee qualifies for certain special enrollment periods, the Exchange must allow the enrollee and his or her dependents to change to another QHP within the same level of coverage (or one metal level higher or lower, if no such QHP is available), as outlined in § 156.140(b). The QRS pilot involved focused consumer testing of the display of quality rating information to maximize the clarity of the information provided and to assess how the information was displayed and used on Exchange websites. One commenter did not support maintaining the high-cost risk pool due to concerns that issuers may try to “game” the system by inflating the costs of high-cost services to push payments over the threshold, and stated that the methodology creates another level of uncertainty that issuers will need to factor into their premiums. Finally, we stated that we believe the change would also ensure more efficient termination of unnecessary or duplicative coverage for consumers who have opted to have their coverage terminated in such circumstances. This final rule, combined with FAQ Part 40, ensures that issuers and group health plans need not make changes to how they have historically handled direct drug manufacturer support amounts. Under such circumstances, the Exchange would terminate coverage retroactively to the date of death, as specified in § 155.430(d)(7), with no requirement to redetermine the eligibility of the deceased enrollee. In accordance with § 155.330(d)(3), Exchanges must periodically examine available data sources (beginning with the 2021 calendar year, generally at least twice per calendar year) to determine whether enrollees in a QHP through an Exchange who are receiving APTC or CSRs have been determined eligible for or are enrolled in other qualifying coverage through Medicare, Medicaid, CHIP, or the BHP, if a BHP is operating Start Printed Page 29201in the service area of the Exchange. [152] As we proposed, the 2021 maximum annual limitation on cost sharing would be $8,550 for self-only coverage and $17,100 for other than self-only coverage. Receipt will fully offset payments over time. Consistent with our analysis in the 2014 through 2020 Payment Notices, we developed three test silver level QHPs, and analyzed the impact on AV of the reductions described in the PPACA to the proposed estimated 2021 maximum annual limitation on cost sharing for self-only coverage ($8,550).
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