CMs-10433 Business Rules Template

OMB control number: 0938-1187
Expiration Date: XX/XX/20XX

2022 Business Rules Template v11.0 [assistivAll fields with an asterisk ( * ) are required. To validate the template, press Validate button or Ctrl + Shift + I. To finalize the template, press Finalize button or Ctrl + Shift + F.
Press TAB and directional arrow keys to read through the document. If macrEnter the Issuer Rule on the first row (no Product ID or Plan ID).

For each Product rule, enter only the Product ID and the business rules that differ from the Issuer Rule.
For each Plan rule, enter only the Plan ID and the business rules that differ from the Product or Issuer Rule.
Issuer level rule will apply only to plan type indicated in cell C10.
HIOS Issuer ID*
Medical, Dental, or Both?*

Product ID

Plan ID
(Standard Component)

Medical or Dental Rule?*

What is the maximum
Is there a maximum age
number of rated underage
for a dependent?
dependents on this policy?

How is age determined
for rating and eligibility
purposes?

How is tobacco status
determined for
subscribers and
dependents?

What relationships between primary
and dependent are allowed, and is
the dependent required to live in the
same household as the primary
subscriber?

PRA DISCLOSURE:
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 for this information collection is
0938-1187, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 24.50 hours issuer per year, including the time to review instructions, gather the information needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any document containing sensitive information to
the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Nicole Levesque at [email protected].