State Rating Requirements
Disclosure Form
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1258.
Instructions:
Complete this disclosure form to provide rating requirements specific to your State and/or to request approval for geographical rating areas. This form must be submitted by the State Department of Insurance or other applicable regulatory agency and signed by an authorized official. You must complete all sections of this form and submit it no later than February 1 of the calendar year prior to which the standard applies. Please provide the names and contact information for at least two people who are knowledgeable about the contents of this form and may serve as contacts for CMS.
Submit the completed form and supporting documents electronically to: [email protected].
Submit any questions to: [email protected].
PART A
State: _______________________
Date of Disclosure: ___________________________
Primary Contact Information
Name: ___________________________
Designation: _____________________________
Address: __________________________________________
Phone: ____________________________________
E-mail: ___________________________________
Secondary Contact Information
Name: ___________________________
Designation: _____________________________
Address: __________________________________________
Phone: ____________________________________
E-mail: ___________________________________
Please indicate whether the state is seeking CMS approval for a number of rating areas in the individual and/or small group market that is greater than the number described in 45 CFR §147.102(b)(3)(ii):
Yes
No
Official authorized to sign this disclosure:
Name and Designation:____________________________________
Signature: __________________________________________
PART B
I. Age Rating Ratio (45 CFR §147.103(a)(1))
Within the individual market, are health insurance issuers in your state required to use an age rating ratio narrower than 3:1?
The state has no specific requirements in the individual market and the state uses a 3:1 age rating ratio.
Yes, the ratio is narrower – details are provided below.
Enter the state’s individual age rating ratio (if narrower than 3:1):__________
Within the small group market, are health insurance issuers in your state required to use an age rating ratio narrower than 3:1?
The state has no specific requirements in the small group market and the state uses a 3:1 age rating ratio.
Yes, the ratio is narrower – details are provided below.
Enter the state’s small group age rating ratio (if narrower than 3:1):__________
Provide details as appropriate, specifying market.
List supporting documents attached, if any.
II. Age Rating Curve (45 CFR §147.103(a)(6))
Within the individual market, are all health insurance issuers in your state required to use a uniform age rating curve other than the federal default age curve?
Yes
No
If yes, provide the age rating curve for the individual market.
Within the small group market, are all health insurance issuers in your state required to use a uniform age rating curve other than the federal default age curve?
Yes
No
If yes, provide the age rating curve for the small group market.
List supporting documents attached, if any.
III. Tobacco Use Rating Ratio (45 CFR §147.103(a)(2))
Within the individual market, are health insurance issuers in your state required to use a tobacco use rating ratio narrower than 1.5:1?
The state has no specific requirements in the individual market and the state uses a 1.5:1 rating ratio.
Yes, the ratio is narrower – details are provided below.
Enter the state’s individual tobacco use rating ratio (if narrower than from 1.5:1): _________
Within the small group market, are health insurance issuers in your state required to use a tobacco use rating ratio narrower than1.5:1?
The state has no specific requirements in the small group market and the state uses a 1.5:1 rating ratio.
Yes, the ratio is narrower – details are provided below.
Enter the state’s small group tobacco use rating ratio (if narrower than1.5:1): ________
Provide details as appropriate, specifying market.
List supporting documents attached, if any.
IV. Single Risk Pool (45 CFR §156.80(c))
Are health insurance issuers in your state required to merge the individual and small group insurance markets into a single risk pool for purposes of section 1312(c) of the Affordable Care Act?
Yes, details are provided below.
No, the markets are always separate and distinct.
No, however, individual and small group market experience is combined to establish a market-adjusted index rate (but the markets are separate for applying plan adjustment factors.
Provide details as appropriate.
List supporting documents attached, if any.
V. Small Group Market Premiums (45 CFR §147.103(a)(5))
Are health insurance issuers in the small group market in your state required to offer to a group health plan premiums that are based on average enrollee premium amounts (composite premiums)?
Yes
No
Provide details as appropriate.
List supporting documents attached, if any.
VI. Geographical Rating Areas (45 CFR §147.103(a)(3))
Within the individual market, are health insurance issuers in your state required to use state-defined geographical rating areas?
Yes, details are provided in 2, 3, 4 and 5 below.
No, the state will use the default rating areas in the individual market.
Enter the number of rating areas (if applicable): ________
Basis for rating areas (if applicable)
Rating areas based on counties
Rating areas based on three-digit zip codes
Rating areas based on metropolitan statistical areas (MSAs) and non-MSAs
Date rating areas were established by law, rule, regulation, or other executive action (if applicable): __________
Is the state seeking CMS approval for a number of rating areas in the individual market that is greater than the number described in 45 CFR §147.102(b)(3)(ii)?
Yes
No
If yes, provide details in 11 and 12 below.
Within the small group market, are health insurance issuers in your state required to use state-defined geographical rating areas?
Yes, details are provided in 7, 8, 9 and 10 below.
No, the state will use the default rating areas in the small group market.
Enter the number of rating areas (if applicable): ________
Basis for rating areas (if applicable)
Rating areas based on counties
Rating areas based on three-digit zip codes
Rating areas based on metropolitan statistical areas (MSAs) and non-MSAs
Date rating areas were established by law, rule, regulation, or other executive action (if applicable): __________
Is the state seeking CMS approval for a number of rating areas in the small group market that is greater than the number described in 45 CFR §147.102(b)(3)(ii)?
Yes
No
If yes, provide details in 11 and 12 below.
Provide detailed description of the proposed rating areas, specifying market.
List supporting documents attached, if any.
VII. Family Tier Structure (45 CFR §147.103(a)(4))
(For states that do not permit any rating variation based on age or tobacco)
Within the individual market, are health insurance issuers in your state required to determine premiums for family coverage by using uniform family tiers and the corresponding multipliers established by the state?
Yes
No
If yes, provide details regarding family tiers and corresponding multipliers for the individual market.
Within the small group market, are health insurance issuers in your state required to determine premiums for family coverage by using uniform family tiers and the corresponding multipliers established by the state?
Yes
No
If yes, provide details regarding family tiers and corresponding multipliers for the small group market.
List supporting documents attached, if any.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | DEPARTMENT OF HEALTH & HUMAN SERVICES |
| Author | Graphics |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |