CMS-10454 State Rating Requirements Disclosure Form

OMB Control Number: 0938-1258
Expiration Date: XX/XX/XXXX

State Rating Requirements
Disclosure Form

PRA Disclosure Statement
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. The time required to complete this
information collection is estimated to average 8 hours per response, including the time to review
instructions, search existing data resources, gather the data 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.

Instructions:
Complete this disclosure form to provide rating requirements specific to your state and/or to
request approval for geographical rating areas or state-specific uniform age rating curves. 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
1. State: _______________________
2. Date of Disclosure: ___________________________
3. Primary Contact Information
Name: ___________________________
Designation: _____________________________
Address: __________________________________________
Phone: ____________________________________
E-mail: ___________________________________
4. Secondary Contact Information
Name: ___________________________
Designation: _____________________________
Address: __________________________________________
Phone: ____________________________________
E-mail: ___________________________________

5. Official authorized to sign this disclosure:
Name and Designation: ____________________________________
Signature: __________________________________________

PART B
I. Sale of QHPs in the Large Group Market
1. Has the state elected to allow issuers to offer qualified health plans (QHPs) in the large
group market through the Exchange in the state pursuant to section 1312(f)(2)(B) of the
Affordable Care Act?
Yes (Please respond to the relevant questions in the sections below. If a state
elects this option, the provisions of 45 CFR 147.102 apply to all coverage offered in
the large group market in the state.)
No

II. Age Rating Ratio (45 CFR §147.103(a)(1))
1. Within the individual market, are health insurance issuers in your state required to use
an age rating ratio for adults narrower than 3:1?
The state uses a 3:1 age rating ratio for adults.
Yes, the ratio for adults is narrower – details are provided below.
2. Enter the state’s individual age rating ratio (if narrower than 3:1):__________
3. Within the small group market, are health insurance issuers in your state required to
use an age rating ratio for adults narrower than 3:1?
The state uses a 3:1 age rating ratio for adults.
Yes, the ratio for adults is narrower – details are provided below.
4. Enter the state’s small group age rating ratio for adults (if narrower than
3:1):__________
5. For states that allow QHPs in the large group market to be offered through the Exchange:
Within the large group market, are health insurance issuers in your state required to
use an age rating ratio for adults narrower than 3:1?
Not applicable
The state uses a 3:1 age rating ratio for adults.
Yes, the ratio for adults is narrower – details are provided below.
6. Enter the state’s large group age rating ratio for adults (if narrower than
3:1):__________
7. Provide details as appropriate, specifying market.

8. List supporting documents attached, if any.

III.

Age Rating Curve (45 CFR §147.103(a)(6))

1. 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
2. If yes, provide the age rating curve for the individual market.

3. 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
4. If yes, provide the age rating curve for the small group market.

5. For states that allow QHPs in the large group market to be offered through the Exchange:
Within the large 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?
Not applicable
Yes
No
6. If yes, provide the age rating curve for the large group market.

7. List supporting documents attached, if any.

IV.

Tobacco Use Rating Ratio (45 CFR §147.103(a)(2))

1. 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 uses a 1.5:1 rating ratio.
Yes, the ratio is narrower – details are provided below.
2. Enter the state’s individual tobacco use rating ratio (if narrower than 1.5:1): _________
3. 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 uses a 1.5:1 rating ratio.
Yes, the ratio is narrower – details are provided below.
4. Enter the state’s small group tobacco use rating ratio (if narrower than 1.5:1):
________
5. For states that allow QHPs in the large group market to be offered through the Exchange:
Within the large group market, are health insurance issuers in your state required to
use a tobacco use rating ratio narrower than1.5:1?
Not applicable
The state uses a 1.5:1 rating ratio.
Yes, the ratio is narrower – details are provided below.
6. Enter the state’s large group tobacco use rating ratio (if narrower than 1.5:1): ________
7. Provide details as appropriate, specifying market.

8. List supporting documents attached, if any.

V.

Single Risk Pool (45 CFR §156.80(c))

1. 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).
2. Provide details as appropriate.

3. List supporting documents attached, if any.

VI.

Composite Premiums (45 CFR §147.103(a)(5))

1. 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
2. For states that allow QHPs in the large group market to be offered through the Exchange:
Are health insurance issuers in the large group market in your state required to offer to
a group health plan premiums that are based on average enrollee premium amounts
(composite premiums)?
Not applicable
Yes
No
3. Provide details as appropriate.

4. List supporting documents attached, if any.

VII.

Geographical Rating Areas (45 CFR §147.103(a)(3))

1. 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.
2. Enter the number of rating areas (if applicable): ________
3. 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
4. Date rating areas were established by law, rule, regulation, or other executive action (if
applicable): __________
5. 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 16 and 17 below.
6. 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.
7. Enter the number of rating areas (if applicable): ________

8. 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
9. Date rating areas were established by law, rule, regulation, or other executive action (if
applicable): __________
10. 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 16 and 17 below.
11. For states that allow QHPs in the large group market to be offered through the Exchange:
Within the large group market, are health insurance issuers in your state required to
use state-defined geographical rating areas?
Not applicable
Yes, details are provided in 12, 13, 14 and 15 below.
No, the state will use the default rating areas in the large group market.
12. Enter the number of rating areas (if applicable): ________
13. 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
14. Date rating areas were established by law, rule, regulation, or other executive action (if
applicable): __________

15. Is the state seeking CMS approval for a number of rating areas in the large group
market that is greater than the number described in 45 CFR §147.102(b)(3)(ii)?
Not applicable
Yes
No
If yes, provide details in 16 and 17 below.

16. Provide detailed description of the proposed rating areas, specifying market.

17. List supporting documents attached, if any.

VIII. Family Tier Structure (45 CFR §147.103(a)(4))
(For states that do not permit any rating variation based on age or tobacco)
1. 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
2. If yes, provide details regarding family tiers and corresponding multipliers for the
individual market.

3. 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
4. If yes, provide details regarding family tiers and corresponding multipliers for the
small group market.

5. For states that allow QHPs in the large group market to be offered through the Exchange:
Within the large 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?
Not applicable
Yes
No
6. If yes, provide details regarding family tiers and corresponding multipliers for the large
group market.

7. List supporting documents attached, if any.