-
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App A, Section A, Background
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Addition
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As
this data collection is intended to provide consumers with an
appropriate educational experience for learning the affordable
health insurance options available to them, it entails two
separate collections of related information. Information on the
individual market is collected at a portal plan (detailed) level,
and comprises detailed benefits information, and data required to
return estimated base rates returned from information provided by
the consumer.
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This section defines the data collection for individual products
in general terms for clarity.
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App A, Section A, Background
|
Addition
|
Small
group insurance is actually purchased in a different manner, such
that small employers generally contract for a suite of products
which allow their employees to choose between different options.
Because of this, benefit information is collected as a set of
available options with more general summaries. As base premiums
would only apply after a small employers consumers choose between
the available options, it was determined that base premiums could
not be reliably collected and displayed. Instead, an estimate of
cost per enrollee is calculated using enrollment and premium
information reported.
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This section defines the small group approach in general terms
for clarity.
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|
App A, Section A, Background
|
Addition
|
Finally,
it should be noted that other developments in the the Health
Insurance market and its regulatory environment have impacted the
collection. While we are not reporting on association products to
consumers at this time, those products have increased their
market share significantly over the last few years. Provisions
are included in this PRA to allow for us to distinguish such
products from those which do not require membership in defined
bodies. It is hoped that this lays the foundation for discussion
with industry and consumers as to how best to display such
information in the future.
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This section defines changes based on the emerging importance of
association insurance products for clarity.
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App A, Section A, Background
|
Addition
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A
second development has been the emergence of a standard for
reporting on health benefits and cost sharing to consumers which
has emerged under the auspices of the NAIC. Referred to as the
Summary of Benefits and Coverage, this standard is currently the
foundation for reporting requirements which have been released
for public comment as an MPRM covering transparency requirements
in Section 2715 of the ACA. As this is an emerging standard, it
was determined that the overall burden would be diminished if
this data collection made similar adjustments. Section 1103 does
require that we be consistent with any such emerging standard.
This standard does request some additional information beyond the
original specification. However, by adopting this standard, we
can reduce the overall burden on issuers by providing a
centralized location for providing this information to consumers,
and allowing for one specification instead of several.
|
This addition explains the shift to using the Summary of Benefits
and Coverage as the new standard for reporting in general terms.
Added for clarity.
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App A, Section A, Background
|
Addition
|
These
changes have evolved from prior experience with the initial
collections and feedback received from industry, consumer
representatives, and internal stakeholders. The new
specifications of this package reflect those changes, as is made
clear from the accompanying Revision Crosswalk.
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Paragraph added for reading flow and to make clear that a cross
walk of changes is available.
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App A, Section A, Background
|
Edit
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Changed:
This draft is being
provided for the60 day period for comment by the public.
To:
A prior draft of
this document was submitted for 60 day period for comment by the
public. This version reacts to comments received, and provides
the final version for 30 day review.
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Reflect the stage of the process accurately.
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App A, Setion 4, Duplication of Efforts
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addition
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Additionally, in order to leverage the experience of issuers in
this collection for other data requirements, it is anticipated
that this portal will be utilized for other CCIIO collections
such as rate review filings and possibly medical loss ratios.
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Edit to delineate rationale for approach.
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App A, Setion 15, Changes to Burden
|
Edit
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Change:
The current
estimate for the burden on issuers exceeds the initial annual
estimate by $328,610.
To:
The current estimate for the burden on issuers
is a reduction of $755,200 from the initial estimates provided in
2010.
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The comment was confusing, as the change was not based on the
original estimate, but on a revised estimate for a period covered
by an interim PRA. The numbers are further explained through the
addition of a chart
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-
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App A, Setion 15, Changes to Burden
|
Addition
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Table added with numbers
from emergency PRA submission 08/09/2010, and replication of
existing chart within current document showing current costs.
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Added at OMB request.
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App C, Subsequent Data Collection, M(c)
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Added
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Authorized Data
Attestation Officials: Two factor authentication will require
that basic contact information will need to be collected.
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Security requirements for two factor authentication required a
change to attestation such that email and phone information now
be collected for attestors (CEO/CFO). This security change has
not yet gone into production, and issuers will be notified before
implementation.
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App C, Subsequent Data Collection Section N
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Deletion
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Company Overview - A brief description of the company appropriate
for consumers will be provided. This may include separate data
components for year of founding, the number of employees,
subsidiaries and affiliates, corporate awards, description of the
coverage area, membership and the provider network.
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The set of questions regarding general corporate information has
been removed, which allowed for removing one submission template
from the requirements.
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App C, Subsequent Data Collection Section C
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Inserted
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C. Number of administrative denials: Some individuals apply for
insurance products which they do not qualify for due to
membership limitations, applying outside of open enrollment, etc.
These types of denials will be tracked separately to make sure
insurers are not penalized in the calculation of denial
percentages.
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Question added based on discussion with industry. Including this
question will allow for more accurate reporting of denials.
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App C, Subsequent Data Collection Section G
|
|
Chnaged:
Additional types of
insurance product statuses will also be included, such as
association product status and whether a product has been
grandfathered.
To:
G. Special Product Categories: Additional
types of insurance product statuses will be collected to allow
for proper rate review and other reporting. These include
association product status and whether a product has been
grandfathered.
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Edited for clarity - designation as association or as
grandfathered are now two separate fields.
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D-1
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App D, September 3 Data Requirement: Benefits and Pricing
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Deletion
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Portal Plan enrollment: Number of covered lives for the most
recent completed fiscal quarter.
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Based on comments by industry, enrollment will no longer be
captured at both product and portal plan level to reduce burden
and concerns over confidentiality.
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D-6
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App D, Medical Benefits Information- Small Group Market
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Insertion
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Medical Benefits Information-
Small Group Market
While the decision
was made to utilize the “Summary of Benefits and Coverage”
(SBC) developed by the insurance industry and regulators through
the National Association of Insurance Commissioners (NAIC), it is
recognized that this is especially problematic for small group
products in which a particular portal plan is not specified at
the time a small employer enrolls with an insurer. As such, a
modified approach to identify the set of cost sharing benefits at
a product level is being proposed as delineated below.
The following items
will be collected in the format consistent as possible with the
SBC at a product level.
HSA Eligible:
Insurers will need to indicate this information under the
instruction to Enter Y or N
Annual
Deductible, In Network: Insurers will need to indicate this
information under the instruction to Enter the available
deductibles separated by commas (ex 1000, 2000, 2500, etc.)"
Annual
Deductible, Out of Network: Insurers will need to indicate this
information under the instruction to Enter the available
deductibles separated by commas (ex 1000, 2000, 2500, etc.)"
Copay, In
Network: Insurers will need to indicate this information under
the instruction to Enter the minimum and maximum copay separated
by commas (ex 0, 50)"
Copay, Out of
Network: Insurers will need to indicate this information under
the instruction to Enter the minimum and maximum copay separated
by commas (ex 0, 50)"
"Coinsurance,
In Network: Insurers will need to indicate this information
under the instruction to Enter the minimum and maximum
coinsurance separated by commas (ex 0%, 40%)"
"Coinsurance,
Out of Network: Insurers will need to indicate this information
under the instruction to Enter the minimum and maximum
coinsurance separated by commas (ex 0%, 40%)"
Annual
Out-of-Pocket Limit, In Network: Insurers will need to indicate
this information under the instruction to Enter the maximum
annual out of pocket net of deductibles, copay and coinsurance."
Annual Max
Benefit, In Network: Insurers will need to indicate this
information under the instruction to Enter the highest annual
max benefit"
Overall
Deductible: Insurers will need to indicate this information
under the instruction to
Other
deductibles for specific services: Insurers will need to
indicate this information under the instruction to
Out-of-Pocket
limit: Insurers will need to indicate this information under the
instruction to
Not included
in Out-of-Pocket: Insurers will need to indicate this
information under the instruction to
Overall annual
limit on insurer payment: Insurers will need to indicate this
information under the instruction to
Does the plan
use a network of providers?: Insurers will need to indicate this
information under the instruction to
Specialist
referral required?: Insurers will need to indicate this
information under the instruction to
Are there
services this plan doesn't cover?: Insurers will need to
indicate this information under the instruction to
Primary care
visit to treat an injury or illness: Insurers will need to
indicate this information under the instruction to enter
“Covered, Not Covered, Covered with Limitations, Covered
at Additional Cost”
Specialist
visit: Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Other
practitioner office visit: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Preventive
care/screening/immunization: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Diagnostic
test (x-ray, blood work): Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Imaging
(CT/PET scans, MRIs): Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Generic drugs:
Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Preferred
brand drugs: Insurers will need to indicate this information
under the instruction to enter “Covered, Not Covered,
Covered with Limitations, Covered at Additional Cost”
Non-preferred
brand drugs: Insurers will need to indicate this information
under the instruction to enter “Covered, Not Covered,
Covered with Limitations, Covered at Additional Cost”
Specialty
drugs (e.g., chemotherapy): Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Outpatient
facility fee (example, ambulatory surgery center): Insurers will
need to indicate this information under the instruction to enter
“Covered, Not Covered, Covered with Limitations, Covered
at Additional Cost”
Outpatient
Physician/ surgeon fees: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Emergency room
services: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Emergency
medical transportation: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Urgent care:
Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Hospitalization
facility fee (example: hospital room): Insurers will need to
indicate this information under the instruction to enter
“Covered, Not Covered, Covered with Limitations, Covered
at Additional Cost”
Hospitalization
Physician/surgeon fee: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Mental/Behavioral
health outpatient services: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Mental/
Behavioral health inpatient services: Insurers will need to
indicate this information under the instruction to enter
“Covered, Not Covered, Covered with Limitations, Covered
at Additional Cost”
Substance use
disorder outpatient services: Insurers will need to indicate
this information under the instruction to enter “Covered,
Not Covered, Covered with Limitations, Covered at Additional
Cost”
Substance use
disorder inpatient services: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Prenatal and
postnatal care: Insurers will need to indicate this information
under the instruction to enter “Covered, Not Covered,
Covered with Limitations, Covered at Additional Cost”
Delivery and
all inpatient services: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Home health
care: Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Rehabilitation
services: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Habilitation
services: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Skilled
nursing care: Insurers will need to indicate this information
under the instruction to enter “Covered, Not Covered,
Covered with Limitations, Covered at Additional Cost”
Durable
medical equipment: Insurers will need to indicate this
information under the instruction to enter “Covered, Not
Covered, Covered with Limitations, Covered at Additional Cost”
Hospice
service: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Eye exam:
Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Glasses:
Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Dental
check-up: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Acupuncture:
Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Bariatric
Surgery: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Non-emergency
care when travelling outside the U.S.: Insurers will need to
indicate this information under the instruction to enter
“Covered, Not Covered, Covered with Limitations, Covered
at Additional Cost”
Chiropractic
Care: Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Cosmetic
Surgery: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Dental care
(adult): Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Hearing aids:
Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Infertility
treatment: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Long-term
care: Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Private-duty
nursing: Insurers will need to indicate this information under
the instruction to enter “Covered, Not Covered, Covered
with Limitations, Covered at Additional Cost”
Routine eye
care (adult): Insurers will need to indicate this information
under the instruction to enter “Covered, Not Covered,
Covered with Limitations, Covered at Additional Cost”
Routine foot
care: Insurers will need to indicate this information under the
instruction to enter “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost”
Weight loss programs: Insurers will need
to indicate this information under the instruction to enter
“Covered, Not Covered, Covered with Limitations, Covered
at Additional Cost”
|
In prior versions of the PRA, the areas of coverage for small
group and individual products were listed together. The sections
have now been separated. This is to allow us to distinguish
between how the are answered. While individual benefits are still
collected at a plan level which allows for detailed response,
small group is reported at product level, and issuers select from
a drop down box with four options. This section is entered as a
block to emphasize it duplicates what already existed except for
being moved to a new section and the detailed reporting changed
for each field to “Covered, Not Covered, Covered with
Limitations, Covered at Additional Cost” (10/6/2011)
|
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D-6
|
App D, Eligibility and Rating Information
|
Deleted
|
Replace
“Eligibility
and Rating Information, Small Group Market
Pricing
of small group market health insurance plans can be determined by
a wide variety of factors presenting unique challenges for
producing premium estimates. In order to allow for consumers to
quickly generate a reasonably representative price estimate,
healthcare.gov will utilize a “limited census”
approach in which small business owners would input general
information about their company. This approach allows issuers to
report more basic data which can still be used to develop a
reasonable representation of a base price estimate.
Base Rates:
Issuers will be required to provide a table including base rates
for the given plan by age bands, gender, and user types. User
types include employee only, employee and spouse, employee and
child(ren), and family.
Effective Date
Trend Factor: As small groups often have built in adjustments
for increases in rates over time, issuers will be required to
provide any multiplicative factors that may be appropriate based
on an enrollee’s projected start date.
Situs location
factors: Issuers who adjust rates based on physical location of
the work site will be required to provide multiplicative factors
which can be applied based on the primary location of the work
site by zipcode or other geographic indicator.
Size Factor:
Issuers will be required to provide any multiplicative factor
they use to vary rates based on the size of the company to be
covered.
Industry
Factor: Issuers will be required to provide any multiplicative
factors they use to vary rates based on industrial
classifications. Provision will be made for entry of these
factors by either the Standard Industrial Classification (SIC)
codes or the North American Industry Classification System
(NAICS).
Initial
Community rating: Issuers will identify whether an individual’s
person health experience will be used exclusively for base price
adjustments to the initial premium or whether a combination of
personal and group health experience, or on some combination of
personal, group, and State experience (community rating) is
utilized.
Renewal
Community rating: Issuers will identify whether an individual’s
person health experience will be used exclusively for renewal
price adjustments or whether a combination of personal and group
health experience, or on some combination of personal, group,
and State experience (community rating) is utilized.
Specified
rating factors: In some states ratings are allowed to vary based
on gender and/or the inclusion of children. In cases where the
given rate estimation structure may not capture the appropriate
dimensions, issuers will be asked to identify what additional
factors are utilized. If non-identified factors create a strata
for plan pricing, we will ask to be informed of those factors.
|
After discussion with industry, the approach for displaying a
cost to consumers was changed. This list of elements necessary to
collect and report base rates was eliminated. It is replaced by a
single element listed separately.
|
-
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D6
|
App D, Eligibility and Rating Information
|
Addition
|
“Eligibility
and Rating Information, Small Group Market
Pricing of small
group market health insurance plans is difficult to identify with
specificity beforehand, as small employers will often shop for a
product which provides a range of choices to their members. As
such, it can be difficult to identify a particular cost point,
even though they still need to be able to assess the cost impact
on them.
As a solution to
this difficulty, an approach is being utilized which shows the
average cost per covered life within a product. This has an
additional advantage of significantly reducing the cost of
reporting.
Total written
premiums: Issuers will report the sum total of written premiums
over the course of an annual quarter for the specified small
group product. This number will be divided by the number of
covered lives reported.”
|
This single element is being used in conjunction with enrollment
to produce a cost estimate. This approach was adopted after
discussion with industry and internal stakeholders.
|
-
|
D-8
|
App D, End of document
|
Edit
|
Business Rules Information,
Small Group Market
Pricing
of small group market health insurance plans can be determined by
a wide variety of factors presenting unique challenges for
producing premium estimates. In order to allow for consumers to
quickly generate a reasonably representative price estimate,
healthcare.gov will utilize a “limited census”
approach in which small business owners would input general
information about their company. This approach allows issuers to
report more basic data which can still be used to develop a
reasonable representation of a base price estimate.
Situs location
factors: Issuers who adjust rates based on physical location of
the work site will be required to provide multiplicative factors
which can be applied based on the primary location of the work
site by zipcode or other geographic indicator.
Size Factor:
Issuers will be required to provide any multiplicative factor
they use to vary rates based on the size of the company to be
covered.
Is
the service area/rate structure based on the employer or
employee location: A plan’s rates may be calculated based
on place of employment or on an employee’s place of
residence. We must ascertain this to provide estimates of
premium estimation.
Service
area coverage: In some cases, a service area may be defined
within which an employee must reside for coverage. Issuers will
be asked to identify if that is the case with a given plan, and
whether that service areas boundaries correspond to the boundary
of the state.
Minimum
participation/contribution requirements: A specification of the
minimal percentage of employees or employee contributions which
would be required for enroll into the plan to be allowed.
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.
|
This content was previously included under the deleted section
regarding rating. It has been moved after the single element for
total written premium. This move is purely administrative.
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