Current through Reg. 50, No. 13; March 28, 2025
(a) An issuer
may not use a rate with respect to a plan if:
(1) the issuer has not filed the rate with
TDI for review;
(2) the rate filing
does not comply with the standards in §
3.503 of this title (relating to
Rating Standards); or
(3) the rate
filing has been withdrawn.
(b) Each issuer must submit an annual rate
filing no later than June 15 for any individual or small group market plan that
will be issued effective on or after January 1 in the following calendar year.
A small group issuer may include scheduled quarterly trend increases within the
annual rate filing. An issuer may have only one active annual single risk pool
rate filing in each market. An issuer may not modify an annual rate filing
later than October 1 prior to the calendar year for which the filing was
submitted.
(c) A small group issuer
may submit a rate filing for a quarterly rate change that takes effect on April
1, July 1, or October 1. A small group issuer may have only one active
quarterly single risk pool rate filing at a given time. Notwithstanding §
26.11 of this title (relating to
Restrictions Relating to Premium Rates), a small group issuer must submit a
quarterly rate filing at least 105 days before the effective date of the rate
change.
(d) A rate filing must
include the index rate for the single risk pool and reflect every product and
plan that is part of the single risk pool in the applicable market. Issuers are
not required to enter CSR plan variations separately.
(e) Rate filings made under this subchapter
must be submitted through the electronic system designated by TDI, according to
any technical instructions provided for the electronic system and consistent
with the rules and procedures in Chapter 3, Subchapter A, of this title
(relating to Submission Requirements for Filings and Departmental Actions
Related to Such Filings) and §
11.301 of this title (relating to
Filing Requirements).
(f) Rate
filings made under this subchapter must include the following:
(2) for a rate increase that is 15% or more
within a 12-month period that begins on January 1, as determined by
45 CFR §
154.200(b) and (c),
concerning Rate Increases Subject to Review, a written description justifying
the rate increase (Part II) that complies with
45 CFR §
154.215(e), concerning
Submission of Rate Filing Justification;
(3) rating filing documentation (Part III)
that complies with
45 CFR §
154.215(f) and that includes
an unredacted actuarial memorandum signed by a qualified actuary;
(4) a rates table that identifies the
applicable rate for each plan, depending on an individual's rating area,
tobacco use, and age;
(5) an
enrollment spreadsheet that contains, with respect to each county:
(A) the number of covered lives, as of March
31 of the current year, that are enrolled in each of the following plan types,
separated on the basis of whether the enrollment is through the federal
exchange or off-exchange:
(iii) silver plans, separated as follows:
(I) silver plans with an AV of 70%;
(II) silver plans with an AV of
73%;
(III) silver plans with an AV
of 87%;
(IV) silver plans with an
AV of 94%; and
(V) silver plans
with an AV of 100%;
(B) whether the
plan is available in the county in the current calendar year; and
(C) whether the plan will be available in the
county in the next calendar year; and
(6) an AV and cost-sharing factor spreadsheet
that contains:
(A) the plan ID specified in
the URRT; and
(B) the component
factors of an AV and cost-sharing design of plan field in the URRT, which
should not include adjustments that account for the morbidity of the population
expected to enroll in the plan, including:
(i)
the AV of the plan, calculated consistent with
45 CFR §
156.135, concerning AV Calculation for
Determining Level of Coverage;
(ii)
the induced-demand factor of 1.00 for bronze plans, 1.03 for silver plans, 1.08
for gold plans, and 1.15 for platinum plans; and
(iii) for individual silver plans on the
exchange, a CSR adjustment factor of 1.35, that accounts for the average costs
attributable to CSRs, to the extent that issuers are not otherwise being
reimbursed for those costs. If issuers are being reimbursed for those costs by
HHS, consistent with
42
USC §
18071, concerning Reduced
Cost-Sharing for Individuals Enrolling in Qualified Health Plans, then the CSR
adjustment factor would not apply.
(g) Issuers may submit data using the
templates available on TDI's website at
www.tdi.texas.gov/health/ratereview.html.
(h) On request from TDI, an issuer must
provide any additional information needed to evaluate the rate
filing.
(i) An issuer that does not
intend to issue a plan that would require a rate filing for the next calendar
year, but that has enrollment in a plan that is subject to this subchapter in
the current year or the prior year, must submit the data for such plan under
paragraphs (1) and (2) of this subsection, as applicable, to TDI no later than
June 15. For example, in June of 2022, an issuer must submit data under
paragraph (1) of this subsection for the 2021 calendar year, and data under
paragraph (2) of this subsection for the first five months of calendar year
2022. An issuer that does not have data to submit under paragraph (2) of this
subsection is still required to submit data under paragraph (1) of this
subsection.
(1) For prior year cumulative
data, an issuer must submit:
(A) allowed claim
costs, defined as total payments made under the plan to health care providers
on behalf of covered members and including payments made by the issuer, member
cost-sharing, cost-sharing paid by HHS on behalf of low-income members, and net
payments from any federal or state reinsurance arrangement or
program;
(B) incurred claim costs,
defined as allowed claim costs as specified in subparagraph (A) of this
paragraph, less member cost-sharing, cost-sharing paid by HHS on behalf of
low-income members, and any net payments from a federal or state reinsurance
arrangement;
(2) For current year cumulative
data through March 31, an issuer must submit:
(C) the enrollment spreadsheet required under
subsection (f)(5) of this section.
