CMS-10320.Appendix_E_BenefitsPremiumsInformation

Appendix E - Benefits and Pricing
September 3 Data Requirement: Benefits and Pricing
As Section 1103(b)(2) makes clear, the ability of consumers to decide on affordable
health care options requires additional information on benefits and cost sharing
associated with a product. Specifically, the Secretary requires information on the
“percentage of total premium revenue expended on nonclinical costs (as reported under
section 2718(a) of the Public Health Service Act), eligibility, availability, premium rates,
and cost sharing with respect to such coverage options.”
To ensure accurate information, consistent presentation, and to minimize the burden on
issuers, collection of this data will be delayed until after the May 21 collection. As of
September 3, 2010, however, issuers will be required to provide information on the
portal plan level as specified below.
Company Profile and Contact Information
A. Issuer Name: Issuer name shall be provided as the legal name of the entity registered to
provide the plan within the coverage area.
B. IRS Federal Employer Identification Number (EIN): Issuers are required to provide the
employer identification number under which they pay taxes to the IRS. This element is
obtained solely to allow for unique identification of the entities, and required verification of
information.
C. NAIC Company Code Number: Issuers are required to provide the NAIC Company Code
number if they have one.
D. State: State in which plan coverage is offered.
E. Market type: In order to appropriately direct consumers, issuers will indicate whether the
product specified is an individual or small group offering.
F. NAIC Group Code: If a company has an NAIC Group code, we ask that this be provided for
administrative tracking.
G. Company Overview - A brief description of the company appropriate for consumers will be
provided. This may also include separate data components for year of founding, the number
of employees, subsidiaries and affiliates, corporate awards, logo, description of the coverage
area, membership and the provider network.
H. Company address - The mailing address for the corporation.
I. Company URL - Universal resource locator for the company website.
J. Customer Service Phone number and TTY phone - For corporate contact.
K. Customer service email: For reaching corporate customer service.
L. Grievance and appeals contact: Issuers will submit the phone number and or URL for
customers to contact them with grievances or appeals.
M. Data Submission Contact and backup (Phone Number & E-mail Address): Essential for
reaching primary person responsible for the initial data entry.
N. Data Validation Contact and backup (Phone Number & E-mail Address): Person who will
review and approve the submitted information on the web site before it goes live.
O. Rating: The issuer should report whether or not they have been rated by an independent
company, the source of that rating, and what the rating is.
P. Plan enrollment: Number of covered lives for the most recent completed fiscal quarter.

Q. System for Electronic and Rate Form Filing (SERFF) number –The SERFF number by which
many states accept applications for product level form filings will be added to plan level
records.

Medical Benefits Information
A. Deductible: The specified dollar amount for which consumers are responsible for health care
costs before the health insurance plan begins to pay for health care services. If a deductible
applies to the plan we will require that this information be provided. Distinction will be made
between in-network and out-of-network deductibles. Categories of deductibles will be
collected to identify how a given plan distributes it’s cost sharing.
B. Coinsurance: We will require a brief description of when co-insurance is applied, and what
percentage is covered.
C. Out of Pocket Limit: This is defined as an annual cap on the amount of money individuals are
required to pay out-of-pocket for health care costs, excluding the premium cost. Exclusions
will be identified.
D. Primary Care Physician Required: This factor has significant effects on the relationship
between a patient and their doctor, and as such is of importance to consumers, thus the
Secretary will require it be reported.
E. Specialist Referrals Required: issuers will need to indicate to consumers whether a referral
from their primary care physician is needed before seeing a specialist.
F. HSA Eligibility: Health Savings Accounts HSAs are one avenue used by many consumers to
manage overall health care expenses. We will ask whether HSAs are supported under the
plan.
G. Office Visits: The specified dollar amount, co-pay or coinsurance percentage associated with
specific types of office visits. Types of visits will include: primary care physician office visit,
specialist visits, periodic health exams, OB-GYN exam visits, and well baby care.
H. Prescription drug benefits: Insurance plans can treat prescription drug coverage differently,
greatly affecting the costs for particular consumers. We will require issuers to provide the
main dimensions of their drug coverage to ascertain co-pays, co-insurance and deductible for
formulary drugs, brand name drugs, and generic drugs obtained from pharmacies or through
mail order.
I. Additional Coverage: Other factors which are critical for individuals choosing insurance will be
covered with specific questions regarding Lab/X-Ray work, Emergency Room visits,
Outpatient Surgery, Hospitalization, Pre & Postnatal office visits, and Labor & Delivery
Hospital Stays. We will require brief descriptions of the coverage of these items.
J. Dental Benefits: A description of dental benefits will be required, including whether there is a
separate plan into which one is automatically enrolled, annual deductibles and maximums,
coverage of general preventative procedures as well as more expensive options such as
dental surgery and orthodontics.
K. Out-of-Network Coverage: A yes or no field regarding whether out of network care is covered
combined with brief descriptions of the plan on this aspect will be required (including
deductible, coinsurance, out-of-pocket-limit, and pre-authorization requirements).
L. Out-of-Country Coverage: A yes/no or short description of whether care obtained outside the
country is covered under the plan. This information may be of critical importance to
consumers who travel internationally.
M. Medical Records coverage: Are the costs of obtaining medical records covered under the
plan.
N. Self directed account: (Small Group Only) A Self Directed Account is a health insurance plan
that provides an annual dollar credit that can be used to pay for covered services. Any
unused portion of the dollar credit may be carried over and added to the next year's credit if
continuously enrolled in the plan. This information will be collected for small group plans.

O. Family Calculations (Individual Only): Some plans have separate family deductibles, out of
pocket expenses, and/or maximums for coverage. The Secretary will ascertain whether these
conditions exist and how they relate to the quoted personal amounts.
P. Chiropractic Services: Coverage of chiropractic services will be requested and include
whether services are covered and how charges relate to the deductible, percent co-pay or coinsurance, number of visits per year, and maximum benefit amount.
Q. Mental Health Services: Coverage of mental health services will be required and include
whether services are covered and how charges relate to the deductible, percent co-pay or coinsurance, number of visits per year, number of maximum inpatient stays, and maximum
benefit amount.
R. Substance Abuse Treatment Coverage: Coverage of substance abuse treatment will be
required and include whether services are covered and how charges relate to the deductible,
percent co-pay or co-insurance, number of visits per year, number of maximum inpatient
stays, and maximum benefit amount.
S. Annual Limit: The annual limits imposed on payments from an insurer for coverage will be
identified both for in-network and out of network coverage.
T. Exclusions: Identified medical coverage and procedures which are excluded from service will
be identified .

Eligibility and Rating Information, Individual Market
Various factors go in to the calculation of an individual consumer’s out-of-pocket
expenses for an insurance package. Currently, many states allow for medical underwriting which can affect a person’s actual premiums through such issues as life-style
choices and pre-existing medical conditions. To accurately reflect these issues, it will be
imperative to gather information about how the issuer determines insurance rates.
The secretary will explore the best way to reflect these myriad differences in pricing
schemes to provide the best estimate of costs possible. The data requirement will
cover:
A. US citizenship. Is US citizenship required for plan membership.
B. Domestic Partnerships: Can domestic partners be covered under this plan. Does this include
same sex domestic partners.
C. State citizenship: Under some plans, an applicant must have resided within the state for a
certain period of time before coverage will be extended. We will require those limits be
identified.
D. Other eligibility requirements: In cases where other non-health related questions are used to
determine eligibility, the secretary will require that these be specified.
E. Age limits: Some plans have a maximum or minimum age for either primary applicants or for
dependents. In cases where this is true, we will those limits will be noted.
F. Effective Dates: Given enrollment periods may sometimes differ, as can the time period
during which rates are in effect. issuers will be required to identify the appropriate dates.
G. How often do rate updates typically occur?
H. Other categories: issuers in different states may apply a variety of specific non-medical
conditions for membership or for the application of different pricing schemes. Plans may be
limited to non-smokers, available only to particular occupations, or be subject to any number
of limits. Where such categorical determinations exist, the issuers will be required to identify
them.
I. Administrative Fees: If monthly fees are required by the plan, we will require that they be
specified for the consumer.
J. Issuer fee Conditions: If issuer fees are applied, issuers will be required to identify the
conditions for their application and calculation.

K. Rate calculation: Individual rates may be calculated on a number of different dimensions
even before medical underwriting or even if medical underwriting doesn’t apply. Issuers will
be required to provide information on how their rates are calculated. It is anticipated that most
issuers will be able to provide this by use of a “rate table” providing a breakdown by variables
such as gender, age, smoking status, and a few additional variables. In cases where such
tables do not adequately describe rating by the issuer, the issuer will provide a programmatic
description of their rating formula in a step by step formula. Where issuers maintain a
verification source which allows for third party comparisons, this information will be provided
to allow the Government to review results from whatever calculations are required on our
part.
L. Additional administrative specifications: Some factors related to how data must be specified
for purposes of filling out applications or other forms will be ascertained. In some cases,
issuers may have specific requirements on how forms must be filled out (such as children
and spouses should be listed in age order).
M. How the service area is defined: In response to concerns from issuers, we are incorporating
the ability to identify service areas by zip code, by county, by a combination, or simply by
state as appropriate.
N. Lifetime maximum: consumers need to be informed of the maximum benefit that issuers will
cover.

Eligibility and Rating Information, Small Group Market
Pricing of small group market health insurance plans can be determined by a wide
variety of factors. In order to capture the broadest range, the Secretary is requesting the
following elements for rate calculations and estimates. These data elements may be
supplemented by a company rate table which identifies the relevant cells for their
specific plans with a pre-calculated rate for those cells.
A. US citizenship. Is US citizenship required for plan membership.
B. Domestic Partnerships: Can domestic partners be covered under this plan
C. State citizenship: Under some plans, an applicant must have resided within the state for a
certain period of time before coverage will be extended. We will require those limits be
identified.
D. Age limits: Some plans have a maximum or minimum age for either primary applicants or for
dependents, and for small groups this may be effected by the size of the group. This
information will be captured through a short series of questions.
E. Rating tier to be quoted: Some issuers will provide rate tables based on a tier structure
applied across plans. In such cases, the tier for a plan must be identified.
F. Whether SIC or NAICS codes are used: An administrative field for identifying the types of
employers who may be covered.
G. Is the service area/rate structure based on the employer or employee location: Rates may be
quoted on the basis of the place of employment or where an employee lives. We muct
ascertain this to provide accurate quotes.
H. Service area coverage: Must an employee live within the service area to be eligible?
I. Should out of state employees be given a rate or quoted $0?
J. Coverage area administrative specifications: To determine the appropriate path for rate
estimation, questions will be asked regarding whether the determination of service areas is
determined in the same way across plans and states.
K. Fees: Issuers will be required to identify whether there are application or administration fees
which consumers should factor into their decision.

L. Age questions: Small group market insurance costs may be affected by the age of
employees, and age cut offs. This effect may also vary by group size or student status or may
be applied to dependents. Questions will be used to determine whether this is the case.
M. Specified rating factors: In some states ratings are allowed to very based on gender and/or
the inclusion of children. If these factors have an effect on rates, we will ask issuers to identify
them.
N. Other factors: If non-identified factors create a strata for plan pricing, we will ask to be
informed of those factors.
O. Minimum participation/contribution requirements: A specification of the minimal percentage of
employees or employee contributions who would be required to enroll.
P. Administrative calculation factors: While most data elements are being collected to display to
consumers or fed directly into rate calculations, others may simply be important for
determining the best approach to incorporate their data. These issues will be covered by a
small set of questions such as the minimum time in business rules, whether rates are
calculated on the basis of tables or through algorithms and a rating engine, and where
verification data may be found if new algorithms must for required by issuers.
Q. Rate calculation specifications: In order to validate and develop ratings solutions, issuers will
be asked to provide a step-by-step description of their ratings process.
R. How the service area is defined: In response to concerns from issuers, we are incorporating
the ability to identify service areas by zip code, by county, by a combination, or simply by
state as appropriate.