Centers for Medicare & Medicaid Services: Federal Funding Methodology for Program Year 2021 Part 2
Continued from Part 1
Household Income (I)
Household income is a significant determinant of the amount of the PTC that is provided for persons enrolled in a QHP through an Exchange. Accordingly, both the current and proposed BHP payment methodologies incorporate household income into the calculations of the payment rates through the use of income-based rate cells. We propose defining household income in accordance with the definition of modified adjusted gross income in 26 U.S.C. 36B(d)(2)(B) and consistent with the definition in 45 CFR 155.300. Income would be measured relative to the FPL, which is updated periodically in the
* 0-50 percent.
* 51-100 percent.
* 101-138 percent.
* 139-150 percent.
* 151-175 percent.
* 176-200 percent.
We further propose to assume a uniform income distribution for each federal BHP payment cell. We believe that assuming a uniform income distribution for the income ranges proposed would be reasonably accurate for the purposes of calculating the BHP payment and would avoid potential errors that could result if other sources of data were used to estimate the specific income distribution of persons who are eligible for or enrolled in the BHP within rate cells that may be relatively small.
Thus, when calculating the mean, or average, PTC for a rate cell, we propose to calculate the value of the PTC at each 1 percentage point interval of the income range for each federal BHP payment cell and then calculate the average of the PTC across all intervals. This calculation would rely on the PTC formula described in section II.D.5. of this proposed notice.
As the advance payment of PTC (APTC) for persons enrolled in QHPs would be calculated based on their household income during the open enrollment period, and that income would be measured against the FPL at that time, we propose to adjust the FPL by multiplying the FPL by a projected increase in the CPI-U between the time that the BHP payment rates are calculated and the QHP open enrollment period, if the FPL is expected to be updated during that time. We propose that the projected increase in the CPI-U would be based on the intermediate inflation forecasts from the most recent OASDI and Medicare Trustees Reports.[16]
5. Premium Tax Credit Formula (PTCF)
In Equation 1 described in section II.A.1. of this proposed notice, we propose to use the formula described in 26 U.S.C. 36B(b) to calculate the estimated PTC that would be paid on behalf of a person enrolled in a QHP on an Exchange as part of the BHP payment methodology. This formula is used to determine the contribution amount (the amount of premium that an individual or household theoretically would be required to pay for coverage in a QHP on an Exchange), which is based on (A) the household income; (B) the household income as a percentage of FPL for the family size; and (C) the schedule specified in 26 U.S.C. 36B(b)(3)(A) and shown below.
The difference between the contribution amount and the adjusted monthly premium (that is, the monthly premium adjusted for the age of the enrollee) for the applicable second lowest cost silver plan is the estimated amount of the PTC that would be provided for the enrollee.
The PTC amount provided for a person enrolled in a QHP through an Exchange is calculated in accordance with the methodology described in 26 U.S.C. 36B(b)(2). The amount is equal to the lesser of the premium for the plan in which the person or household enrolls, or the adjusted premium for the applicable second lowest cost silver plan minus the contribution amount.
The applicable percentage is defined in 26 U.S.C. 36B(b)(3)(A) and 26 CFR 1.36B-3(g) as the percentage that applies to a taxpayer's household income that is within an income tier specified in Table 1, increasing on a sliding scale in a linear manner from an initial premium percentage to a final premium percentage specified in Table 1. We propose to continue to use applicable percentages to calculate the estimated PTC that would be paid on behalf of a person enrolled in a QHP on an Exchange as part of the BHP payment methodology as part of Equation 1. We propose that the applicable percentages in Table 1 for calendar year (CY) 2020 would be effective for BHP program year 2021. The applicable percentages will be updated in future years in accordance with 26 U.S.C. 36B(b)(3)(A)(ii).
6. Metal Tier Selection Factor (MTSF)
On the Exchange, if an enrollee chooses a QHP and the value of the PTC to which the enrollee is entitled is greater than the premium of the plan selected, then the PTC is reduced to be equal to the premium. This usually occurs when enrollees eligible for larger PTCs choose bronze-level QHPs, which typically have lower premiums on the Exchange than silver-level QHPs. Prior to 2018, we believed that the impact of these choices and plan selections on the amount of PTCs that the federal government paid was relatively small. During this time, most enrollees in income ranges up to 200 percent FPL chose silver-level QHPs, and in most cases where enrollees chose bronze-level QHPs, the premium was still more than the PTC. Based on our analysis of the percentage of persons with incomes below 200 percent FPL choosing bronze-level QHPs and the average reduction in the PTCs paid for those enrollees, we believe that the total PTCs paid for persons with incomes below 200 percent FPL were reduced by about 1 percent in 2017. Therefore, we did not seek to make an adjustment based on the effect of enrollees choosing non-silver-level QHPs in developing the BHP payment methodology applicable to program years prior to 2018. However, after the discontinuance of the CSR payments in
The discontinuance of the CSR payments led to increases in silver-level QHP premiums (and thus in the total potential PTCs), but did not generally increase the bronze-level QHP premiums in most states; we believe this is the primary reason for the increase in the percentage reduction in PTCs paid by the government for those who enrolled in bronze-level QHPs between 2017 and 2018. Therefore, we now believe that the impacts on the amount of PTC the government would pay due to enrollees' plan selection choices are larger and thus more significant, and we are proposing to include an adjustment (the MTSF) in the BHP payment methodology to account for the effects of these choices. Section 1331(d)(3) of the Affordable Care Act requires that the BHP payments to states be based on what would have been provided if such eligible individuals were allowed to enroll in QHPs, and we believe that it is appropriate to consider how individuals would have chosen different plans--including across different metal tiers--as part of the BHP payment methodology.
We finalized the application of the MTSF for the first time in the 2020 payment methodology, and here we propose to calculate the MTSF using the same approach as finalized there (84 FR 59543). First, we would calculate the percentage of enrollees with incomes below 200 percent of the FPL (those who would be potentially eligible for the BHP) in non-BHP states who enrolled in bronze-level QHPs in 2018. Second, we would calculate the ratio of the average PTC paid for enrollees in this income range who selected bronze-level QHPs compared to the average PTC paid for enrollees in the same income range who selected silver-level QHPs. Both of these calculations would be done using CMS data on Exchange enrollment and payments.
The MTSF would then be set to the value of 1 minus the product of the percentage of enrollees who chose bronze-level QHPs and 1 minus the ratio of the average PTC paid for enrollees in bronze-level QHPs to the average PTC paid for enrollees in silver-level QHPs:
MTSF = 1-(percentage of enrollees in bronze-level QHPs x (1-average PTC paid for bronze-level QHP enrollees/average PTC paid for silver-level QHP enrollees))
We have calculated that 12.68 percent of enrollees in households with incomes below 200 percent of the FPL selected bronze-level QHPs in 2018. We also have calculated that the ratio of the average PTC paid for those enrollees in bronze-level QHPs to the average PTCs paid for enrollees in silver-level QHPs was 76.66 percent after adjusting for the average age of bronze-level and silver-level QHP enrollees. The MTSF is equal to 1 minus the product of the percentage of enrollees in bronze-level QHPs (12.68 percent) and 1 minus the ratio of the average PTC paid for bronze-level QHP enrollees to the average PTC paid for silver-level QHP enrollees (76.66 percent). Thus, the MTSF would be calculated as:
Therefore, we propose that the value of the MTSF for 2021 would be 97.04 percent.
We believe it is reasonable to use the same value for the MTSF as was used in the 2020 payment methodology. First, we currently do not have more recent and complete data available than the 2018 data that was used to calculate the value of the MTSF finalized in the 2020 payment methodology. At this time, we only have data for several months of 2019. Second, the MTSF reflects the percentage of enrollees choosing bronze-level QHPs and the accompanying reduction in the PTCs paid. We recognize that there may be changes to these over time, but we do not expect significant year-to-year differences absent other changes to the operations of the Exchanges (for example, the discontinuance of CSR payments). As detailed above, we believe that states and QHP issuers have not significantly changed their approaches to add adjustments to account for the discontinuation of CSR payments to QHP premiums, and that most states and QHP issuers are using similar approaches as were used in 2018. We further believe that consumers will continue to react to these adjustments and increases in silver-level QHP premiums in the same manner; meaning that consumers will continue to select bronze-level QHPs and the impact on PTCs paid by the government will generally remain the same. Therefore, we believe that our proposal to maintain the value of the MTSF at 97.04 percent is reasonable for program year 2021.
We request comments on this proposal. In particular, we welcome comments on whether other sources of data beyond 2018 are available and should be used to calculate the MTSF for 2021. For example, one potential alternative would be to update the MTSF with partial 2019 data collected by CMS for Exchange plan selection and enrollment (by income and by metal tier selection) and for APTC paid for 2021 (based on the number of months available at the time the final payment methodology is published). Another potential alternative would be to leverage the ability to make retrospective adjustments under Section 600.610(c)(2)(iii) to update the value for the MTSF for program year 2021 to reflect actual 2021 experience once the necessary data for 2021 are available, which would be after the end of the program year.
7. Income Reconciliation Factor (IRF)
For persons enrolled in a QHP through an Exchange who receive APTC, there will be an annual reconciliation following the end of the year to compare the advance payments to the correct amount of PTC based on household circumstances shown on the federal income tax return. Any difference between the latter amounts and the advance payments made during the year would either be paid to the taxpayer (if too little APTC was paid) or charged to the taxpayer as additional tax (if too much APTC was paid, subject to any limitations in statute or regulation), as provided in 26 U.S.C. 36B(f).
Section 1331(e)(2) of the Affordable Care Act specifies that an individual eligible for the BHP may not be treated as a "qualified individual" under section 1312 of the Affordable Care Act who is eligible for enrollment in a QHP offered through an Exchange. We are defining "eligible" to mean anyone for whom the state agency or the Exchange assesses or determines, based on the single streamlined application or renewal form, as eligible for enrollment in the BHP. Because enrollment in a QHP is a requirement for individuals to receive PTC, individuals determined or assessed as eligible for a BHP are not eligible to receive APTC assistance for coverage in the Exchange. Because they do not receive APTC assistance, BHP enrollees, on whom the BHP payment methodology is generally based, are not subject to the same income reconciliation as Exchange consumers.
Nonetheless, there may still be differences between a BHP enrollee's household income reported at the beginning of the year and the actual household income over the year. These may include small changes (reflecting changes in hourly wage rates, hours worked per week, and other fluctuations in income during the year) and large changes (reflecting significant changes in employment status, hourly wage rates, or substantial fluctuations in income). There may also be changes in household composition. Thus, we believe that using unadjusted income as reported prior to the BHP program year may result in calculations of estimated PTC that are inconsistent with the actual household incomes of BHP enrollees during the year. Even if the BHP adjusts household income determinations and corresponding claims of federal payment amounts based on household reports during the year or data from third-party sources, such adjustments may not fully capture the effects of tax reconciliation that BHP enrollees would have experienced had they been enrolled in a QHP through an Exchange and received APTC assistance.
Therefore, in accordance with current practice, we propose including in Equation 1 an adjustment, the IRF, that would account for the difference between calculating estimated PTC using: (a) Household income relative to FPL as determined at initial application and potentially revised mid-year under Section 600.320, for purposes of determining BHP eligibility and claiming federal BHP payments; and (b) actual household income relative to FPL received during the plan year, as it would be reflected on individual federal income tax returns. This adjustment would seek prospectively to capture the average effect of income reconciliation aggregated across the BHP population had those BHP enrollees been subject to tax reconciliation after receiving APTC assistance for coverage provided through QHPs offered on an Exchange. Consistent with the methodology used in past years, we propose estimating reconciliation effects based on tax data for 2 years, reflecting income and tax unit composition changes over time among BHP-eligible individuals.
The OTA maintains a model that combines detailed tax and other data, including Exchange enrollment and PTC claimed, to project Exchange premiums, enrollment, and tax credits. For each enrollee, this model compares the APTC based on household income and family size estimated at the point of enrollment with the PTC based on household income and family size reported at the end of the tax year. The former reflects the determination using enrollee information furnished by the applicant and tax data furnished by the
For 2021, OTA has estimated that the IRF for states that have implemented the Medicaid eligibility expansion to cover adults up to 133 percent of the FPL will be 99.23 percent, and for states that have not implemented the Medicaid eligibility expansion and do not cover adults up to 133 percent of the FPL will be 98.41 percent.
In previous program years, we used the average of these two values to set the value for the IRF. At the outset of the BHP, we did not know which states would choose to operate a BHP and whether they would be states that implemented the Medicaid eligibility expansion for adults up to 133 of the FPL or states that have not. In addition, there was not a meaningful difference between the two estimated values in the initial program years.[17] Therefore, at that time we believed that using the average of the factors was the appropriate approach. However, to date, the only states that have operated a BHP are states that implemented the Medicaid eligibility expansion and the majority of enrolles in these BHPs have incomes between 133 percent and 200 percent FPL. In addition, no other states have chosen to operate a BHP, and in recent years we have seen estimated IRF values that suggests there is a meaningful difference in the expected results of income reconciliation between states that have and have not expanded Medicaid eligibility.[18]
For these reasons, we believe that it is appropriate to refine the calculation of the IRF and only use data regarding Exchange enrollees with incomes between 133 percent and 200 percent FPL, as in Medicaid expansion states, instead of an average that also includes data regarding Exchange enrollees with incomes between 100 percent and 200 percent FPL, as in non-Medicaid expansion states. For the IRF, given that we have the values for this factor for individuals with incomes between 100 percent and 200 percent FPL and between 133 percent and 200 percent FPL separately, and the estimated 2021 IRF values demonstrate there is a meaningful difference in the expected results of income reconciliation between states that have and have not expanded Medicaid eligibility, we propose to set the value of the IRF for program year 2021 based on those with incomes between 133 percent and 200 percent FPL only, as in Medicaid expansion states. For other factors used in the BHP payment methodology, it may not always be possible to separate the experiences between different types of states and there may not be meaningful differences between the experiences of such states. Therefore, we propose to set the value of the IRF equal to the value of the IRF for states that have expanded Medicaid eligibility, which is 99.23 percent for program year 2021.
E. State Option To Use Prior Program Year QHP Premiums for BHP Payments
In the interest of allowing states greater certainty in the total BHP federal payments for a given plan year, we have given states the option to have their final federal BHP payment rates calculated using a projected ARP (that is, using premium data from the prior program year multiplied by the premium trend factor (PTF)), as described in Equation (2b). We propose to continue to require states to make their election to have their final federal BHP payment rates calculated using a projected ARP by
For Equation (2b), we propose to continue to define the PTF, with minor proposed changes in calculation sources and methods, as follows:
PTF: In the case of a state that would elect to use the 2020 premiums as the basis for determining the 2021 BHP payment, it would be appropriate to apply a factor that would account for the change in health care costs between the year of the premium data and the BHP program year. This factor would approximate the change in health care costs per enrollee, which would include, but not be limited to, changes in the price of health care services and changes in the utilization of health care services. This would provide an estimate of the adjusted monthly premium for the applicable second lowest cost silver plan that would be more accurate and reflective of health care costs in the BHP program year.
For the PTF we propose to use the annual growth rate in private health insurance expenditures per enrollee from the National Health Expenditure (NHE) projections, developed by the
We note that the increase in premiums for QHPs from 1 year to the next may differ from the PTF developed for the BHP funding methodology for several reasons. In particular, we note that the second lowest cost silver plan may be different from one year to the next. This may lead to the PTF being greater than or less than the actual change in the premium of the second lowest cost silver plan.
F. State Option To Include Retrospective State-Specific Health Risk Adjustment in Certified Methodology
To determine whether the potential difference in health status between BHP enrollees and consumers in an Exchange would affect the PTC and risk adjustment payments that would have otherwise been made had BHP enrollees been enrolled in coverage through an Exchange, we propose to continue to provide states implementing the BHP the option to propose and to implement, as part of the certified methodology, a retrospective adjustment to the federal BHP payments to reflect the actual value that would be assigned to the population health factor (or risk adjustment) based on data accumulated during that program year for each rate cell.
We acknowledge that there is uncertainty with respect to this factor due to the lack of available data to analyze potential health differences between the BHP and QHP populations, which is why, absent a state election, we propose to use a value for the PHF (see section II.D.3. of this proposed notice) to determine a prospective payment rate which assumes no difference in the health status of BHP enrollees and QHP enrollees. There is considerable uncertainty regarding whether the BHP enrollees will pose a greater risk or a lesser risk compared to the QHP enrollees, how to best measure such risk, the potential effect such risk would have had on PTC, and risk adjustment that would have otherwise been made had BHP enrollees been enrolled in coverage through an Exchange. To the extent, however, that a state would develop an approved protocol to collect data and effectively measure the relative risk and the effect on federal payments of PTCs and CSRs, we propose to continue to permit a retrospective adjustment that would measure the actual difference in risk between the two populations to be incorporated into the certified BHP payment methodology and used to adjust payments in the previous year.
For a state electing the option to implement a retrospective population health status adjustment as part of the BHP payment methodology applicable to the state, we propose requiring the state to submit a proposed protocol to CMS, which would be subject to approval by us and would be required to be certified by the Chief Actuary of CMS, in consultation with the OTA. We propose to apply the same protocol for the population health status adjustment as what is set forth in guidance in Considerations for Health Risk Adjustment in the Basic Health Program in Program Year 2015 (http://www.medicaid.gov/Basic-Health-Program/Downloads/Risk-Adjustment-and-BHP-White-Paper.pdf). We propose requiring a state to submit its proposed protocol for the 2021 program year by
III. Collection of Information Requirements
The proposed methodology for program year 2021 is similar to the methodology finalized for program year 2020 in the
We are seeking comment on whether or not to solicit information from QHP issuers on the amount of the adjustment to premiums to account for the discontinuance of CSR payments. We believe that soliciting such information would likely impose some additional reporting requirements on QHP issuers, and we welcome comments on the amount of burden this would create.
IV. Response to Comments
Because of the large number of public comments we normally receive on
V. Regulatory Impact Analysis
A. Statement of Need
Section 1331 of the Affordable Care Act (42 U.S.C. 18051) requires the Secretary to establish a BHP, and section 1331(d)(1) specifically provides that if the Secretary finds that a state meets the requirements of the program established under section 1331(a) of the Affordable Care Act, the Secretary shall transfer to the state federal BHP payments described in section 1331(d)(3). This proposed methodology provides for the funding methodology to determine the federal BHP payment amounts required to implement these provisions for program year 2021.
B. Overall Impact
We have examined the impacts of this rule as required by Executive Order 12866 on Regulatory Planning and Review (
Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). Section 3(f) of Executive Order 12866 defines a "significant regulatory action" as an action that is likely to result in a rule: (1) Having an annual effect on the economy of
A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects (
C. Anticipated Effects
The provisions of this proposed notice are designed to determine the amount of funds that will be transferred to states offering coverage through a BHP rather than to individuals eligible for federal financial assistance for coverage purchased on the Exchange. We are uncertain what the total federal BHP payment amounts to states will be as these amounts will vary from state to state due to the state-specific factors and conditions. For example, total federal BHP payment amounts may be greater in more populous states simply by virtue of the fact that they have a larger BHP-eligible population and total payment amounts are based on actual enrollment. Alternatively, total federal BHP payment amounts may be lower in states with a younger BHP-eligible population as the RP used to calculate the federal BHP payment will be lower relative to older BHP enrollees. While state composition will cause total federal BHP payment amounts to vary from state to state, we believe that the methodology, like the methodology used in 2020, accounts for these variations to ensure accurate BHP payment transfers are made to each state.
The Regulatory Flexibility Act (5 U.S.C.
Because this methodology is focused solely on federal BHP payment rates to states, it does not contain provisions that would have a direct impact on hospitals, physicians, and other health care providers that are designated as small entities under the RFA. Accordingly, we have determined that the methodology, like the previous methodology and the final rule that established the BHP program, will not have a significant economic impact on a substantial number of small entities.
Section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a methodology may have a significant economic impact on the operations of a substantial number of small rural hospitals. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan statistical area and has fewer than 100 beds. For the preceding reasons, we have determined that the methodology will not have a significant impact on a substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act (UMRA) of 2005 requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of
Executive Order 13132 establishes certain requirements that an agency must meet when it issues a final rule that imposes substantial direct effects on states, preempts state law, or otherwise has federalism implications. The BHP is entirely optional for states, and if implemented in a state, provides access to a pool of funding that would not otherwise be available to the state. Accordingly, the requirements of Executive Order 13132 do not apply to this proposed notice.
D. Alternative Approaches
We considered several alternatives in developing the proposed BHP payment methodology for 2021, and we discuss some of these alternatives below.
We considered alternatives as to how to calculate the PAF in the proposed methodology for 2021. The proposed value for the PAF is 1.188, which is the same as was used for 2018, 2019, and 2020. We believe it would be difficult to get the updated information from QHP issuers comparable to what was used to develop the 2018 factor, because QHP issuers may not distinctly consider the impact of the discontinuance of CSR payments on the QHP premiums any longer. We do not have reason to believe that the value of the PAF would change significantly between program years 2018 and 2021. We are continuing to consider whether or not there are other methodologies or data sources we may be able to use to develop the PAF. We are also considering whether or not to update the value of the PAF for 2021 after the end of the 2021 BHP program year.
We also considered alternatives as how to calculate the MTSF in the proposed methodology for 2021. The proposed value for the MTSF is 97.04 percent, which is the same as was finalized for 2020. We believe that we would use the latest data available each year; for example, we anticipate data from 2019 being available next year in developing the subsequent BHP payment methodology. We are considering whether or not there are other methodologies or data sources we may be able to use to develop the MTSF. We are also considering whether or not to update the value of the MTSF for 2021 after the end of the 2021 BHP program year.
We considered alternatives as how to calculate the IRF in the proposed methodology for 2021. We are proposing to calculate the value of this factor based on modeling by OTA, as we have done for prior years. For the 2021 BHP payment methodology, we are considering calculating the IRF from the latest available year of Exchange data. We do not anticipate this would lead to a significant change in the value of the IRF. In addition, we also considered whether to set the IRF as the average of the expected values for states that have expanded Medicaid eligibility and for states that have not, or to set the IRF as the value for only states that have expanded Medicaid eligibility, because only states that have expanded eligibility have operated a BHP to date.
We also considered whether or not to continue to provide states the option to develop a protocol for a retrospective adjustment to the population health factor (PHF) as we did in previous payment methodologies. We believe that continuing to provide this option is appropriate and likely to improve the accuracy of the final payments.
We also considered whether or not to require the use of the program year premiums to develop the federal BHP payment rates, rather than allow the choice between the program year premiums and the prior year premiums trended forward. We believe that the payment rates can still be developed accurately using either the prior year QHP premiums or the current program year premiums and that it is appropriate to continue to provide the states the option.
Many of the factors proposed in this proposed notice are specified in statute; therefore, for these factors we are limited in the alternative approaches we could consider. One area in which we previously had and still have a choice is in selecting the data sources used to determine the factors included in the proposed methodology. Except for state-specific RPs and enrollment data, we propose using national rather than state-specific data. This is due to the lack of currently available state-specific data needed to develop the majority of the factors included in the proposed methodology. We believe the national data will produce sufficiently accurate determinations of payment rates. In addition, we believe that this approach will be less burdensome on states. In many cases, using state-specific data would necessitate additional requirements on the states to collect, validate, and report data to CMS. By using national data, we are able to collect data from other sources and limit the burden placed on the states. For RPs and enrollment data, we propose using state-specific data rather than national data as we believe state-specific data will produce more accurate determinations than national averages.
We request public comment on these alternative approaches.
E. Regulatory Reform Analysis Under E.O. 13771
Executive Order 13771, titled Reducing Regulation and Controlling Regulatory Costs, was issued on
F. Conclusion
We believe that this proposed BHP payment methodology is effectively the same methodology as finalized for 2020. BHP payment rates may change as the values of the factors change, most notably the QHP premiums for 2020 or 2021. We do not anticipate this proposed methodology to have any significant effect on BHP enrollment in 2021.
In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the
Dated:
Administrator,
Dated:
Secretary,
Footnotes
1. BHP program years span from
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2. "Metal tiers" refer to the different actuarial value plan levels offered on the Exchanges. Bronze-level plans generally must provide 60 percent actuarial value; silver-level 70 percent actuarial value; gold-level 80 percent actuarial value; and platinum-level 90 percent actuarial value. See 45 CFR 156.140.
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3. This curve is used to implement the Affordable Care Act's 3:1 limit on age-rating in states that do not create an alternative rate structure to comply with that limit. The curve applies to all individual market plans, both within and outside the Exchange. The age bands capture the principal allowed age-based variations in premiums as permitted by this curve. The default age curve was updated for plan or policy years beginning on or after
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4. In this document, references to the "current methodology" refer to the 2020 program year methodology as outlined in
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5. For example, a cell within a particular state might refer to "
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6. The three lowest income ranges would be limited to lawfully present immigrants who are ineligible for Medicaid because of immigration status.
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7. See 81 FR at 10097.
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8. CMCS. "State Medicaid, CHIP and BHP Income Eligibility Standards Effective
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9. Some examples of outliers or unreasonable adjustments include (but are not limited to) values over 100 percent (implying the premiums doubled or more as a result of the adjustment), values more than double the otherwise highest adjustment, or non-numerical entries.
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10.
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11. See Basic Health Program: Federal Funding Methodology for Program Years 2019 and 2020; Final Methodology, 84 FR 59529 through 59532 (
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12. See 45 CFR 154.215 and 156.210.
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13. See 79 FR at 14131.
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14. See 45 CFR 153.400(a)(2)(iv) (BHP standard health plans are not required to submit reinsurance contributions), 153.20 (definition of "Reinsurance-eligible plan" as not including "health insurance coverage not required to submit reinsurance contributions"), 153.230(a) (reinsurance payments under the national reinsurance parameters are available only for "Reinsurance-eligible plans").
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15. These income ranges and this analysis of income apply to the calculation of the PTC.
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16. See Table IV A1 from the 2019 Annual Report of the Boards of Trustees of the
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17. For example, the estimated 2016 IRF value was 100.25 percent for states that had expanded Medicaid eligibility and 100.24 percent for states that had not expanded eligibility. See 80 FR 9636 at 9644. Similary, the estimated 2017 IRF value was 100.40 percent for states that expanded Medicaid eligibility and 100.35 percent for those that had not. See 81 FR 10091 at 10101. Additionally, the estimated 2018 IRF values were 97.37 for Medicaid expansion states and 97.45 for non-Medicaid expansion states. See 84 FR 12552 at 12562.
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18. For example, the estimated 2019 IRF value was 98.37 percent for states that expanded Medicaid eligibility and 97.70 for those that had not. Similarly, the estimated 2020 IRF values were 98.91 for Medicaid expansion states and 98.09 for non-Medicaid expansion states. See 84 FR 59529 at 59544.
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[FR Doc. 2020-02472 Filed 2-6-20;
BILLING CODE 4120-01-P
The document is published in the
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Centers for Medicare & Medicaid Services: Federal Funding Methodology for Program Year 2021 Part 1
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