Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Pursuant to section
10290 of the
Insurance Code, a health insurer shall submit all of the following to the
Commissioner together with a health insurance policy form:
(1) Either of the following:
(A) A statement of variables specifying the cost
sharing values for all essential health benefits subject to cost sharing for each
plan submitted.
(B) A schedule of
benefits or similar document specifying the cost sharing values for all essential
health benefits subject to cost sharing for each plan submitted.
(2) Either of the following:
(A) If the benefit design is compatible with the
federal Actuarial Value Calculator, completed Excel tabs entitled "User Inputs for
Plan Parameters" from the calculator for each plan submitted.
(B) If the benefit design is incompatible with the
federal Actuarial Value Calculator, an actuarial certification of the methodology
chosen to determine actuarial value from the two options specified in subsection (b)
of section 156.135 of Title 45 of the Code of Federal Regulations for each plan
submitted.
(b) The
statement of variables shall include all of the following:
(1) Unless a schedule of benefits is submitted for
each plan, specified values for all essential health benefits subject to cost
sharing for each plan submitted.
(2) An
index to the locations of the variable text in the policy form.
(3) Explanation of the purpose for all variable
text in the policy form.
(c)
If the benefit design is incompatible with the federal Actuarial Value Calculator,
meaning that the calculator does not take into account or accommodate all material
aspects of the cost sharing structure, a health insurer shall submit an actuarial
certification containing all of the following:
(1)
A statement of the qualifications of the actuary who prepared the certification. The
certifying actuary shall be a member of the American Academy of Actuaries and shall
meet the qualification standards stated in Qualification Standards for
Actuaries Issuing Statements of Actuarial Opinion in the United States
(American Academy of Actuaries, Jan. 1, 2008 (incorporated by reference)).
(2) A description of the methodology chosen to
determine actuarial value from the two options specified in subsection (b) of
section 156.135 of Title 45 of the Code of Federal Regulations. The description
shall be sufficiently clear and detailed that another qualified health actuary can
make an objective appraisal of the reasonableness of the data, assumptions, factors,
models, methods, formulas, and calculations used to determine the actuarial value
for each plan submitted. The description shall include all of the following:
(A) The data, assumptions, factors, models,
methods, formulas, and calculations used to determine the actuarial value for each
plan submitted.
(B) The actuarial value
for each plan submitted.
(C) A
discussion of the standard population used to determine the actuarial value for each
plan submitted.
(D) Confirmation that
only in-network cost sharing, including multitier networks, was included in the
calculation of actuarial value for each plan submitted.
(3) A statement of opinion attesting to the
following, as applicable:
(A) For the method
described in subsection (b)(2) of section 156.135 of Title 45 of the Code of Federal
Regulations, that the plan design was fit appropriately, in accordance with
generally accepted actuarial principles and methodologies, into the parameters of
the federal Actuarial Value Calculator.
(B) For the method described in subsection (b)(3)
of section 156.135 of Title 45 of the Code of Federal Regulations, that appropriate
adjustments were made, in accordance with generally accepted actuarial principles
and methodologies, to the actuarial value identified by the federal Actuarial Value
Calculator.
(d) When
the actuarial value of a plan associated with a previously submitted health
insurance policy form is no longer within the allowable range for a level of
coverage, a health insurer shall submit either of the following to the Commissioner:
(1) A new or revised policy form together with the
documents required under subdivision (a) of this section demonstrating compliance
with a level of coverage.
(2) If a
change to the text of the policy form is unnecessary, only the documents required
under subdivision (a) of this section demonstrating compliance with a level of
coverage.
(e) If a small group
health insurance policy is offered in conjunction with a health savings account or
an integrated health reimbursement arrangement to which an employer makes
contributions and that may only be used for cost sharing pursuant to subsection (c)
of section 156.135 of Title 45 of the Code of Federal Regulations:
(1) The policy shall include a value or a range of
values for the annual employer contribution to health savings accounts or amounts
newly made available under health reimbursement arrangements for the year for each
plan offered in conjunction with a health savings account or an integrated health
reimbursement arrangement.
(2) A health
insurer shall demonstrate that the actuarial value for each plan offered in
conjunction with a health savings account or an integrated health reimbursement
arrangement is within the allowable range for a level of coverage by including in
the documents required under subdivision (a)(2) of this section the annual employer
contribution to health savings accounts or amounts newly made available under health
reimbursement arrangements for the year.
1. New section
filed 6-13-2013 as an emergency; operative 6-13-2013 (Register 2013, No. 24). A
Certificate of Compliance must be transmitted to OAL by 12-10-2013 or emergency
language will be repealed by operation of law on the following day.
2.
New section refiled 12-9-2013 as an emergency; operative 12-9-2013 (Register 2013,
No. 50). Pursuant to Insurance Code section
10112.27(o)(2)
a Certificate of Compliance must be transmitted to OAL by 6-9-2014 or emergency
language will be repealed by operation of law on the following day.
3.
Certificate of Compliance as to 12-9-2013 order, including renumbering of former
section 2594.6 to section
2594.5 and renumbering and amendment of
former section 2594.7 to section 2594.6, transmitted
to OAL 1-15-2014 and filed 2-24-2014; amendments effective 2-24-2014 pursuant to
Government Code section
11343.4(b)(3)
(Register 2014, No. 9).
Note: Authority cited: Sections
10112.27,
10112.295,
10112.297,
10112.3,
12921 and
12926, Insurance
Code. Reference: Sections
10112.27,
10112.295,
10112.297,
10112.3 and
10290, Insurance
Code.
