Health Insurance Issuers Unified Rate Review PUF 2015
Health Insurance Market place Competition Unified Rate Review PUF 2015
Qualified Health Plan Unified Rate Review PUF 2015
Keywords
Health Insurance
Insurance Marketplace
Rate Review
Insurance Rate Review
Insurance Rate Increase
Insurance Market Competition
Health Insurance Plans Unified Rate Review PUF
The Public Health Service Act (PHSA) and the implementing regulation, establish requirements for health insurance issuers (issuers) offering health insurance coverage for non-grandfathered products in the small group and/or individual markets to submit rate filing information on rate increases to the Centers for Medicare & Medicaid Services (CMS).
John Snow Labs Standard End User License Agreement
Last updated:January 20, 2021
This Standard End User License Agreement (“EULA”) applies to customers of John Snow Labs Inc. (as defined below), using any product of John Snow Labs Inc. on John Snow Labs Marketplace as defined below (hereinafter referred to “you”) and John Snow Labs Inc., a Delaware corporation (“John Snow Labs”, “we” or “us”).
By downloading, installing, and/or using (as applicable) any Product of John Snow Labs (as defined below), you automatically agree to be bound by, and use our Products in compliance with, this EULA. This EULA, together with additional terms and conditions and/or policies referenced herein or located on https://www.johnsnowlabs.com and/or conveyed to you by John Snow Labs, is a legally binding contract between you and John Snow Labs.
PLEASE READ THIS EULA CAREFULLY BEFORE PURCHASING, INSTALLING OR USING OUR PRODUCTS MADE AVAILABLE ON JOHN SNOW LABS MARKETPLACE.
We may make changes to this EULA from time to time. When we do so, we will revise the “last updated” date given above. The then-current version of this EULA will supersede all earlier versions. You agree that your continued use of our Products after such changes have been published to our EULA will constitute your acceptance of such revised EULA.
“Products” means products and services of John Snow Labs that you download and use from listings in John Snow Labs Data Library;
Important Notice
By installing and using our Products, you acknowledge that the use of the Products can be subject to the restrictions and controls imposed by United States export regulations.
You represent and warrant that you do not intend to use the Products for any purpose prohibited by United States export regulations, including, without limitation, terrorism, cyber-attacks, cyber-crimes, money-laundering, industrial espionage, or nuclear, chemical or biological weapons proliferation. Further, you represent and warrant that you are not listed as a denied party on any list governing United States exports.
Eligibility
Our Products can be used by an individual, business or other legal entity, or both. If you are entering into this EULA, or using the Products, on behalf of a company or other legal entity, you represent that you have the authority to bind such entity to this EULA, in which case “you” shall refer to such entity.
In the event you have entered into a separate written agreement with John Snow Labs regarding the Products that contemplates terms that are inconsistent with this EULA, the written agreement shall control and this EULA will not apply to you to the extent inconsistent with such written agreement, or, if such written agreement is contemplated to be in lieu of this EULA, then this EULA shall not apply at all.
Your Access and Use
Subject to your compliance with this EULA, as well as any other applicable policies, John Snow Labs grants you non-exclusive, non-transferable, license to install, access to, modify, and use of, the Products worldwide (subject to applicable export laws) during the term of this EULA (as described below) solely for research, private study and personal use of Products.
This license is personal to you, and you may not resell our Products, permit other users access to our Products through your account. Your right to use our Products is limited by all terms and conditions set forth in this EULA.
Except for your pre-existing rights and this license granted to you, we and our licensors retain all rights, titles and interests in and to our Products, all related intellectual property rights, including trademarks (whether registered or pending), domain and business names. Our Products are protected by applicable intellectual property laws, including United States copyright law and international treaties.
Except for the foregoing license, you have no other rights in the Products and you may not modify, edit, copy, reproduce, create derivative works of, reverse engineer, alter, enhance or in any way exploit the Products in any manner. If you breach any of this EULA, the above license will terminate automatically.
You will be deemed to have taken any action that you permit, assist or facilitate any person or entity to take related to this EULA, your content or use of the Products. You are responsible for end users’ use of your content and the Products. You will ensure that all end users comply with your obligations under this EULA and that the terms of your agreement with each end user are consistent with this EULA. If you become aware of any violation of your obligations under this EULA caused by an end user, you will immediately suspend access to your content and the Products by such end user. We do not provide any support or services to end users unless we have a separate agreement with you or an end user obligating us to provide such support or services.
Restrictions
You will access or use our Products solely via John Snow Labs Data Library.
Except as otherwise explicitly provided in this EULA or as may be expressly permitted by applicable law, you will not, and will not permit or authorize any third party to:
reproduce, modify, translate, enhance, decompile, disassemble, reverse engineer or create derivative works of any of our Products or its technological features or measures;
rent, lease, sell, resell, loan, distribute, or sublicense access to any of our Products;
circumvent or disable any security or technological features or measures of our Products;
use our intellectual property rights without our express prior written authorization;
use our Products for more than one trial period, unless the trial period is extended by John Snow Labs’ prior written permit;
use our Products with an intent to build a competitive product or service, or copy or substantially copy any ideas, features, functions, organization, structure, application program interface, graphics, or user interface of the Products;
store, copy, modify, distribute, or resell any of the information; audio, visual, and audiovisual works, or other content made available on our Products (collectively, “Content”) or compile or collect any Content as part of a database or other work;
use any automated tool (e.g., robots, spiders) to access or use our Products, or to store, copy, modify, distribute, or resell any Content;
circumvent or disable any rights management, usage rules, or other security features of our Products;
use our Products in a manner that overburdens, or that threatens the integrity, performance, or availability of, our Products; or
remove, alter, or obscure any proprietary notices (including copyright and trademark notices) on any portion of our Products or any Content.
Fees and Taxes
Your use of the Products is subject to our fees. All fees are given on our website https://www.johnsnowlabs.com. Except as set forth in this EULA, the fees are non-refundable. We are entitled to revise our fees from time to time.
The fees exclude any federal, state or local taxes, VAT, GST, or similar taxes. You are responsible for identification and payment of all taxes as required by applicable law.
Term and Termination
This EULA will become effective as of the date of your order of Products and shall be in effect until terminated.
John Snow Labs may suspend or terminate your right to use our Products, if you or your end user’s use of the Products:
is in breach of this EULA;
poses a security risk to our Products;
could adversely impact our systems, the Products or other customers;
could subject us, our affiliates, or any third party to liability; or
could be fraudulent.
We may also suspend or terminate your right to use our Products, if you fail to perform your payment obligations, or you have ceased to operate in the ordinary course, made an assignment for the benefit of creditors or similar disposition of your assets, or become the subject of any bankruptcy, reorganization, liquidation, dissolution or similar proceeding.
We may also suspend or terminate your right to use our Products without any reason upon a relevant 30 days’ written notice to you and will refund the unused fees pre-paid by you for access to the Products for the affected time period (if any). Where your access is suspended or terminated by the breach of this EULA or applicable laws, John Snow Labs will will not provide, or be liable for, any refund.
You will cease use of the Products during any period of suspension, or upon termination of this EULA.
All provisions which by their nature are intended to survive termination shall survive termination of this EULA.
Support
If applicable to your Product, John Snow Labs will provide you with the support services. If you use a trial access, support services are excluded. Under this EULA, our support services exclude any installation, training, maintenance services (including any error corrections, bug fixes, or new releases), technical assistance, consulting services, or other services of any kind. Such services are provided at John Snow Labs’ discretion.
From time to time John Snow Labs can perform updates to our software. If available, such updates may include bug fixes, new features and/or enhancements. You are solely responsible for deploying such updates at your own risk and liability.
Access to our Products
We do not provide you with the equipment to access our Products. You are responsible for all fees charged by third parties related to your access and use of our Products (e.g., charges by Internet service providers).
You are responsible for monitoring your use of the Products, including payment of all fees and/or taxes related to such access and use. You agree that John Snow Labs is permitted to request and you hereby consent to provide John Snow Labs information related to your use of the Products for auditing purposes.
You also certify that you are legally permitted to use the Products, and take full responsibility for the selection and use of the Products. This EULA is void where prohibited by law, and the right to use the Products is revoked in such jurisdictions. John Snow Labs makes no claim that the Products may be lawfully used outside of the United States. If you use the Products from outside of the United States, you do so at your own risk and you are responsible for compliance with the laws of jurisdiction.
Privacy Policy
We may collect, store and receive personal and other information about you through our Products. Our collection and use of this information is governed by our Privacy Policy available at https://www.JohnSnowLabs.com/privacy/ which may be amended from time to time.
Links and Third Party Content
Our Products may display, or contain links to, third party products, services, and websites. Any opinions, advice, statements, services, offers, or other information that constitutes part of the content expressed, authored, or made available by other users or other third parties, or which is accessible through or may be located using our Products (collectively, “Third Party Content”) are those of the respective authors or producers and not of us or our shareholders, directors, officers, employees, agents, or representatives.
We do not control Third Party Content and do not guarantee the accuracy, integrity or quality of such Third Party Content. We are not responsible for the performance of, we do not endorse, and we are not responsible or liable for, any Third Party Content or any information or materials advertised in any Third Party Content. By using our Products, you may be exposed to content that is offensive, indecent, or objectionable. We are not responsible or liable, directly or indirectly, for any damage or loss caused to you by your use of or reliance on any goods, services, or information available on or through any third party service or Third Party Content. It is your responsibility to evaluate the information, opinion, advice, or other content available on and through our Products.
Proprietary Rights
John Snow Labs will not obtain any rights under this EULA from you (or your licensors) to your content.
The Products, including software, is and remains the exclusive property of John Snow Labs and its licensors. Except for the access and use rights expressly set forth in this EULA, no license or other rights in or to the Products or John Snow Labs trademark(s) and other intellectual property rights therein, are granted to you, and all such licenses and rights are expressly reserved. You will not remove, alter, or obscure any proprietary notices (including copyright and trademark notices) on any portion of our Products or any Content.
Trademarks
“John Snow Labs,” the John Snow Labs logo, and any other product, business or service name or slogan, whether registered or pending, displayed on our Products are trademarks of John Snow Labs, Inc. or its suppliers or licensors, and may not be copied, imitated or used, in whole or in part, without the prior written permission of John Snow Labs or the applicable trademark holder. You may not use any metatags or any other “hidden text” utilizing “John Snow Labs” or any other name, trademark or product, business or service name of John Snow Labs without our prior written permission. In addition, the look and feel of our Products, including all page headers, custom graphics, button icons and scripts, is the service mark, trademark and/or trade dress of John Snow Labs and may not be copied, imitated or used, in whole or in part, without our prior written permission. All other trademarks, pending trademarks, registered trademarks, product names and company names or logos mentioned in our Products are the property of John Snow Labs Inc. and/or their respective owners. Reference to any products, services, processes or other information, by trade name, trademark, manufacturer, supplier, or otherwise does not constitute or imply endorsement, sponsorship, or recommendation thereof by us.
Disclaimer of Warranties
YOUR USE OF THE PRODUCTS IS AT YOUR SOLE RISK. THE PRODUCTS AND CONTENT EACH ARE PROVIDED ON AN “AS IS” AND “AS AVAILABLE” BASIS. WE AND OUR SUPPLIERS AND LICENSORS EXPRESSLY DISCLAIM ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, AND NON-INFRINGEMENT. WE DO NOT GUARANTEE THE ACCURACY, COMPLETENESS, OR USEFULNESS OF THE PRODUCTS OR ANY CONTENT, AND YOU RELY ON THE PRODUCTS AND CONTENT AT YOUR OWN RISK. ANY MATERIAL THAT YOU ACCESS OR OBTAIN THROUGH OUR PRODUCTS IS DONE AT YOUR OWN DISCRETION AND RISK AND YOU WILL BE SOLELY RESPONSIBLE FOR ANY DAMAGE TO YOUR COMPUTER OR LOSS OF DATA THAT RESULTS FROM THE DOWNLOAD OF ANY MATERIAL THROUGH OUR PRODUCTS. NO ADVICE OR INFORMATION, WHETHER ORAL OR WRITTEN, OBTAINED BY YOU FROM US OR THROUGH OR FROM OUR PRODUCTS WILL CREATE ANY WARRANTY NOT EXPRESSLY STATED IN THIS EULA. SOME STATES MAY PROHIBIT A DISCLAIMER OF WARRANTIES AND YOU MAY HAVE OTHER RIGHTS THAT VARY FROM STATE TO STATE.
Limitation of Liability
WE AND OUR SUPPLIERS AND LICENSORS WILL NOT BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, OR EXEMPLARY DAMAGES, INCLUDING BUT NOT LIMITED TO, DAMAGES FOR LOSS OF PROFITS, GOODWILL, USE, DATA, OR OTHER INTANGIBLE LOSSES (EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF THESE DAMAGES), RESULTING FROM YOUR USE OF OUR PRODUCTS AND CONTENT. UNDER NO CIRCUMSTANCES WILL THE TOTAL LIABILITY OF US AND OUR SUPPLIERS AND LICENSORS OF ALL KINDS ARISING OUT OF OR RELATED TO YOUR USE OF THE PRODUCTS AND CONTENT (INCLUDING BUT NOT LIMITED TO WARRANTY CLAIMS), REGARDLESS OF THE FORUM AND REGARDLESS OF WHETHER ANY ACTION OR CLAIM IS BASED ON CONTRACT, TORT, OR OTHERWISE, EXCEED THE AMOUNTS, IF ANY, THAT YOU HAVE PAID FOR YOUR USE OF THE PRODUCTS AND CONTENT. BECAUSE SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
Indemnity
To the full extent permitted by applicable law, you shall defend, indemnify and hold harmless John Snow Labs, its affiliates and its licensors, and each of their respective employees, officers, directors, and representatives from and against any claims, damages, losses, liabilities, costs, and expenses (including reasonable attorney’s fees) arising out of or relating to any third party claim concerning: (a) your use of the Products; (b) breach of this EULA or violation of applicable law by you; (c) any content or the combination of such content with other software, content or processes, including any claim involving alleged infringement or misappropriation of third-party rights by such content or combination; or (d) breach of any obligation or duty you owe to a third party.
Legal Notices
Enforcement of this EULA will be governed by the laws of the State of Delaware, excluding its conflict and choice of law principles. The exclusive jurisdiction and venue for any claims arising out of or related to this EULA or your use of the Products will lie in the state and federal courts located in Sussex County, within the State of Delaware, and you irrevocably agree to submit to the jurisdiction of such courts. Our failure to enforce any right or provision in this EULA will not constitute a waiver of such right or provision unless acknowledged and agreed by us in writing. In the event that a court of competent jurisdiction finds any provision of this EULA to be illegal, invalid, or unenforceable, the remaining provisions will remain in full force and effect.
Notifications
We may use your contact information to notify you if we have any legitimate interest or if we need to notify you on any important information related to your use of Products. We will not send you newsletters unless you expressly consented to such notifications.
Contacting Us
If you have any questions or concerns about our Products or this EULA, you may contact us by email at support@JohnSnowLabs.com.
The Part I Unified Rate Review template is required to be submitted by all issuers in the individual, small group and/or combined markets that are proposing a rate increase on any single risk pool compliant products. In addition, all issuers applying to offer at least one qualified health plan (QHP) in the state must submit the template for the market in which the QHP would be offered. The template may also be required by regulatory authority for products in the single risk pool. Issuers are required to submit the annual rate change (i.e. January rate changes). Rate Filing Justification (RFJ) submissions must provide sufficient information for state or federal regulators to review rate filings. In addition, CMS may use data submitted on the RFJ to calculate Advance Premium Tax Credit (APTC) payments and Cost-Sharing Reduction (CSR) advance payments.
In addition, quarterly rate increases for the small group market are allowed if allowed by the state regulatory authority. All issuers are required to set the Index Rate for an effective date of January 1 of each year, and file the Index Rate with the applicable regulatory authority. Subject to state requirements, small group issuers are allowed to file subsequent submissions that reset the Index Rate for the remaining quarters of the calendar year.
As of September 1, 2011, the Affordable Care Act and rate review regulation require review of rate increases of 10 percent or more. A non-grandfathered health plan sold in the individual or small group market that increases its rates by 10 percent or more is subject to review to determine whether the increase is unreasonable. Most states and territories have an effective rate review program and will review rate increases submitted by health insurance issuers in their states and territories. CMS will review rate increases in the market(s) where states do not have an effective rate review program. Additionally, effective January 1, 2014, all plans compliant with the rate monitoring and single risk pool requirements of the Affordable Care Act are required to submit all plans within the single risk pool.
For individual and small employer plans not subject to the single risk pool, each rate increase subject to review, a health insurance issuer must submit a Preliminary Justification for each product affected by the increase. This Preliminary Justification consists of the following parts: Part I, Rate Increase Summary: A form that summarizes the data used to determine the rate increase.
CCIIO (Center for Consumer Information and Insurance Oversight) is also making the data in this form available on the CCIIO website for public use. Part II, Written Explanation of the Rate Increase: A simple and brief narrative describing the data provided in Part I and the assumptions used to develop the rate increase, including an explanation of the most significant factors causing the rate increase. Part III, Rate Filing Documentation: Rate filing documentation that CMS uses to determine whether the rate increase is unreasonable. This section of the Preliminary Justification is only required to be filed when CMS is conducting the rate review. It is posted on the CCIIO website.
About this Dataset
Data Info
Date Created
2014-08-28
Last Modified
2019-10-08
Version
2019-10-08
Update Frequency
Annual
Temporal Coverage
2015
Spatial Coverage
United States
Source
John Snow Labs; Centers for Medicare and Medicaid Services;
Health Insurance Issuers Unified Rate Review PUF 2015, Health Insurance Market place Competition Unified Rate Review PUF 2015, Qualified Health Plan Unified Rate Review PUF 2015
Data Fields
Name
Description
Type
Constraints
Company_Legal_Name
Organization’s legal entity name. Name that is associated with the HIOS Issuer ID
string
-
HIOS_Issuer_ID
Health Insurance Oversight system Issuer ID assigned to the legal entity.
integer
level : Nominal
Effective_Date_Of_Rate_Change
The effective date for which rates are being submitted.
datetime
-
Template_ID
Template ID generated by the system
integer
level : Nominal
State
Code for the State
string
-
Market
The applicable market: Individual, Small Group, or Combined. The market chosen must be consistent with the state’s determination of their allowable markets (e.g. if a state chooses to merge the individual and small group market, the issuer must choose “Combined”).
string
-
Product
Insurance product. The term “product” is defined as a unique combination of benefits, various cost sharing options and a network design(s) to a particular service area. “Product” has the same meaning as included in 45 CFR Part 154
string
-
Product_ID
Insurance product ID, the product ID that corresponds with each product. The two-letter state code portion of the Product ID must be entered using capital letters. The “Product ID” should be the product number assigned by HIOS.
string
-
Metal
Insurance Metal: For each “plan” within a product, there is a corresponding metal level, Platinum, Gold, Silver, Bronze and Catastrophic. Plans that are included in a QHP certification application must show the same Metal as is shown in the QHP application
string
-
AV_Metal_Value
The term “actuarial value” is used to describe a manner of estimating the value of a plan, but not a specific manner. AV Metal Value refers to the federal definition of actuarial value as prescribed in 45 CFR Part 156, §156.20. AV requirements for Platinum hold 90%, Gold hold 80%, Silver 70%, Bronze 60% and Catastrophic: Not specified by law
string
-
AV_Pricing_Value
The AV Pricing Value represents the cumulative effect of adjustments made by the issuer to move from the Market Adjusted Index Rate to the Plan Adjusted Index Rate. It is likely to have a spread from one plan to another that emulates the spread in the Plan Adjusted Index Rates of the same plans.
string
-
Plan_Type
Plan Types are Indemnity, PPO, POS, HMO or EPO. The term “plan” is defined as a unique combination of benefits to a specific set of cost sharing options and network design(s) to a particular service area.
string
-
Plan_Name
The name of each plan within a product. The term “plan” is defined as a unique combination of benefits to a specific set of cost sharing options and network design(s) to a particular service area.
string
-
Plan_ID_Standard_Component_ID
Assigned Plan ID. The two-letter state code portion of the Plan ID must be entered using capital letters. The Plan ID is a unique identifier for the set of benefits and cost sharing values offered within a product by the HIOS issuer, or in other words, a unique identifier of each plan. Plan IDs contain three digits. This field must be entered as a text input and must include any leading zeros (e.g. 001).
string
-
Exchange_Plan
Exchange plan, is an indicator as to whether the plan will be offered inside a State-based or Federally Facilitated Exchange or Small Business Health Options Program (SHOP), regardless of whether or not it will also be offered in the outside market. If an application for qualified health plan status is pending, it is indicated “yes.” This indicator should not be used to identify whether a plan is offered on a private exchange.
number
level : Ratio
Historical_Rate_Increase_Calendar_Year_2
For each product, the historical rate increase for the period two years prior to the current calendar year.
number
level : Ratio
Historical_Rate_Increase_Calendar_Year_1
For each product, the historical rate increase for the period of one year prior to the current calendar year.
number
level : Ratio
Historical_Rate_Increase_Calendar_Year_0
For each product, the historical rate increase for the current calendar year.
number
level : Ratio
Effective_Date_Of_Proposed_Rate
The corresponding effective date of the proposed rate increases.
datetime
-
Rate_Change_In_Percent_Over_Prior_Filing
Average change in premium rates over the rates included in the prior filing for each plan. All products and plans must have the same effective date.
The average change in premium rates over the twelve month period prior to the effective date for each plan. This should be the premium weighted average of the 12-month increases that apply at renewal. For new plans enter -999.00% in this field. It is important to enter this value in the template in this case so other calculated fields in the template are correctly generated.
For each plan, the percentage change in rates between the Experience Period and the Projection Period is shown. This is a calculated field.
number
level : Ratio
Product_Threshold_Rate_Increase_In_Percent
The template calculates the threshold rate increase for each product. This is the rate increase that determines whether the rate increase is subject to review, per 45 CFR Part 154 §154.200.
number
level : Ratio
Plan_Rate_Increase_By_Inpatient
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product.
number
level : Ratio
Plan_Rate_Increase_By_Outpatient
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product.
number
level : Ratio
Plan_Rate_Increase_By_Professional
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product.
number
level : Ratio
Plan_Rate_Increase_By_Prescription_Drug
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product.
number
level : Ratio
Plan_Rate_Increase_By_Other
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product. If the information is entered with the product level variation, this means the issuer enters the information for the total product spread evenly across all plans within the product. If the issuer chooses this methodology, the proposed rate increase for each plan within the product must be identical.
number
level : Ratio
Plan_Rate_Increase_By_Capitation
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product. If the information is entered with the product level variation, this means the issuer enters the information for the total product spread evenly across all plans within the product. If the issuer chooses this methodology, the proposed rate increase for each plan within the product must be identical.
number
level : Ratio
Plan_Rate_Increase_By_Administration
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product. If the information is entered with the product level variation, this means the issuer enters the information for the total product spread evenly across all plans within the product. If the issuer chooses this methodology, the proposed rate increase for each plan within the product must be identical.
number
level : Ratio
Plan_Rate_Increase_By_Taxes_And_Fees
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product. If the information is entered with the product level variation, this means the issuer enters the information for the total product spread evenly across all plans within the product. If the issuer chooses this methodology, the proposed rate increase for each plan within the product must be identical.
number
level : Ratio
Plan_Rate_Increase_By_Risk_And_Profit_Change
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product. If the information is entered with the product level variation, this means the issuer enters the information for the total product spread evenly across all plans within the product. If the issuer chooses this methodology, the proposed rate increase for each plan within the product must be identical.
number
level : Ratio
Plan_Total_Rate_Increase
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product. If the information is entered with the product level variation, this means the issuer enters the information for the total product spread evenly across all plans within the product. If the issuer chooses this methodology, the proposed rate increase for each plan within the product must be identical.
number
level : Ratio
Plan_Member_Cost_Share_Increase
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product. If the information is entered with the product level variation, this means the issuer enters the information for the total product spread evenly across all plans within the product. If the issuer chooses this methodology, the proposed rate increase for each plan within the product must be identical.
number
level : Ratio
Plan_Average_Current_Rate_PMPM
Is a Component of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM. This can be completed with variations only at the product level or variations at each plan level within a product. If the information is entered with the product level variation, this means the issuer enters the information for the total product spread evenly across all plans within the product. If the issuer chooses this methodology, the proposed rate increase for each plan within the product must be identical.
number
level : Ratio
Plan_Projected_Member_Months
The projected member months by plan that correspond to the effective period of the rates for each plan.
number
level : Ratio
Base_Period_Average_Rate_PMPM
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The average premium rate PMPM for each plan during the experience period. The average should be generated using membership consistent with the Experience Period for each plan.
number
level : Ratio
Base_Period_Member_Months
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The total member months during the Experience Period should be consistent with the Experience Period Member Months.
number
level : Ratio
Base_Period_Total_Premium
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The total premium earned in the Experience Period for each plan is calculated as the Average Rate PMPM multiplied by the Member Months in a given plan.
number
level : Ratio
Base_Period_EHB_Basis_Or_Full_Portion_Of_TP
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The percentage of the total premium that is associated with EHB services in each plan (including administrative expenses and profit associated with those services).
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The percentage of the total premium for each plan that is associated with state mandated benefits that are not part of the EHB package.
string
-
Base_Period_Other_Benefits_Portion_Of_TP
The information shown in this section captures the historical data for the twelve month period used in the base period experience. This is a calculated field which generates the remaining percentage of the total premium based on the values entered from the EHB and state mandated benefits portions, described above.
string
-
Base_Period_Total_Allowed_Claims
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The total allowed claims for each benefit plan with service dates within the Experience Period. The Total Allowed Claims (TAC) across all benefit plans for the Experience Period should be consistent with the Allowed Claims
number
level : Ratio
Base_Period_EHB_Basis_Or_Full_Portion_Of_TAC
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The percentage of the total allowed claims that are associated with EHB services in each plan during the Experience Period.
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The percentage of the total allowed claims for each plan that are associated with state mandated benefits that are not part of the EHB package.
string
-
Base_Period_Other_Benefits_Portion_of_TAC
The information shown in this section captures the historical data for the twelve month period used in the base period experience.This is a calculated field which generates the remaining percentage of the total allowed claims based on the values entered from the EHB and state mandated benefits portions. As stated previously, the sum of the EHB portion, the state mandated benefit portion not associated with EHBs and the other benefits portion should equal 100%.
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The portion of the total dollars that are attributable to HHS during the Experience Period. This is the cost sharing reduction subsidies.
The information shown in this section captures the historical data for the twelve month period used in the base period experience. This is a calculated field and displays the percentage of claims covered by HHS over the value of all claims not covered by the issuer.
The information shown in this section captures the historical data for the twelve month period used in the base period experience. This is a calculated field and displays the percentage of claims covered by HHS over the value of all claims not covered by the issuer.
number
level : Ratio
Base_Period_Net_Amount_Of_Reinsurance
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The Federal reinsurance amount received for each plan during the Experience Period.
number
level : Ratio
Base_Period_Net_Amount_Of_Risk_Adjusted
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The risk transfer charge or payment during the Experience Period for each plan
number
level : Ratio
Base_Period_Incurred_Claims_PMPM
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Base_Period_Allowed_Claims_PMPM
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Base_Period_EHB_Portion_Of_Allowed_Claims_PMPM
The information shown in this section captures the historical data for the twelve month period used in the base period experience. The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Projected_Plan_Adjusted_Index_Rate
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
number
level : Ratio
Projected_Member_Months
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state). The template populates the projected Member Months using the Projected Member Months.
number
level : Ratio
Projected_Total_Premium
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
number
level : Ratio
Projected_EHB_Basis_Or_Full_Portion_Of_TP
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
string
-
Projected_Other_Benefits_Portion_Of_TP
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
string
-
Projected_Total_Allowed_Claims
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
number
level : Ratio
Projected_EHB_Basis_Or_Full_Portion_Of_TAC
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
string
-
Projected_Other_Benefits_Portion_Of_TAC
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state). The portion of the total dollars attributable to HHS during the projection period. This is the cost sharing reduction subsidies.
number
level : Ratio
Projected_Net_Amount_Of_Reinsurance
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
number
level : Ratio
Projected_Net_Amount_Of_Risk_Adjusted
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
number
level : Ratio
Projected_Incurred_Claims_PMPM
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
number
level : Ratio
Projected_Allowed_Claims_PMPM
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
number
level : Ratio
Plan_Section_4_Plan_Member_Months
The number of member months expected to be covered
number
level : Ratio
Projected_EHB_Portion_Of_Allowed_Claims_PMPM
The projected data is for the twelve month period following the effective date for each plan. The information is entered at the product level or at the plan level. These circumstances occur in the small group market when prospective trend is included in the submission (if permitted by the state).
number
level : Ratio
Plan_Section_4_Plan_Adjusted_Index_Rate
The Plan Adjusted Index Rate is the Market Adjusted Index Rate further adjusted for plan specific factors allowed by 45 CFR Part 156.80(d)(2) such as provider network, utilization management, benefits in addition to Essential Health Benefits (EHBs), actuarial value and cost sharing, distribution and administrative costs (less Exchange fees) and catastrophic plan eligibility variation.
number
level : Ratio
Plan_Section_4_Total_Premium
The total premium earned in the projection period for each plan is calculated as the Average Rate PMPM multiplied by the Member Months in a given plan.
number
level : Ratio
Plan_Section_4_EHB_Basis_Or_Full_Portion_Of_TP
The percentage of the total premium that is associated with EHB services in each plan (including administrative expenses and profit associated with those services). When calculating the EHB Percent of TP, the Administrative Expense Load, Profit & Risk Load, and Taxes & Fees should be allocated to the various categories in this section (EHB, state mandated benefits that are not EHB, and other benefits) of the template in proportion to the claims expenses.
The percentage of the total premium for each plan that is associated with state mandated benefits that are not part of the EHB package.
number
level : Ratio
Plan_Section_4_Net_Amount_Of_Risk_Adjusted
The amount of any risk transfer payment expected to be received during the projection period for each plan. If a risk transfer charge is anticipated to be assessed, the value entered should be negative.
number
level : Ratio
Plan_Section_4_Other_Benefits_Portion_Of_TP
This is a calculated field which generates the remaining percentage of the total premium based on the values entered from the EHB and state mandated benefits portions, described above. As stated previously, the sum of the EHB portion, the state mandated benefit portion not associated with EHBs and the other benefits portion should equal 100%.
number
level : Ratio
Plan_Section_4_Total_Allowed_Claims
The total allowed claims for each benefit plan with service dates within the projection period
number
level : Ratio
Plan_Section_4_Net_Amount_Of_Reinsurance
The Federal reinsurance amount expected to be received for each plan during the projection period, net of the reinsurance assessments
number
level : Ratio
Plan_Section_4_EHB_Basis_Or_Full_Portion_Of_TAC
The percentage of the total allowed claims for each plan that are associated with state mandated benefits that are not part of the EHB package.
The percentage of the total premium for each plan that is associated with state mandated benefits that are not part of the EHB package. Similar to the EHB percentage, the state mandated benefit percentage of the total premium should include the portion of administrative expenses, taxes and fees and risk and profit loads associated with these services.
This is a calculated field which generates the remaining percentage of the total premium based on the values entered from the EHB and state mandated benefits portions, described above.
This is a calculated field and displays the percentage of claims covered by HHS over the value of all claims not covered by the issuer.
number
level : Ratio
Plan_Section_4_Incurred_Claims_PMPM
The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Plan_Section_4_Plan_Allowed_Claims_PMPM
The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Plan_EHB_Portion_Of_Allowed_Claims_PMPM
The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Experience_Period_Member_Months
The total number of months of coverage in the experience period for all members that had coverage during any portion of the Experience Period.
The amount of premium earned during the Experience Period, net of rebates to policyholders on an incurred basis due to the medical loss ratio (MLR) requirements as defined in 45 CFR § 158.
number
level : Ratio
Allowed_Claims_Amount
The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Incurred_Claims_Amount_In_Experience_Period
Total claims incurred in the Experience Period.
number
level : Ratio
Incurred_Claims_In_Experience_Period_PMPM
PMPM incurred claims amount in the experience period
number
level : Ratio
Allowed_Claims_PMPM
The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Single_Risk_Pool_Gross_Premium_Average_Rate_PMPM
The issuer is required to provide support that the single risk pool in a particular state and market is established according to the requirements in 45 CFR § 156.80(d).
number
level : Ratio
Projected_Member_Month_Projected_Experience
The number of member months expected to be covered during the Projection Period.
The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
number
level : Ratio
Projected_Incurred_Claims_Projected_Period_Totals
The template calculates aggregate dollar amounts for Section III PMPM values entered into or calculated by the template. The amounts are calculated by multiplying the Projected Member Months by the applicable PMPM value.
Projected reinsurance recoveries, referred to as reinsurance payments in the HHS Notice of Benefit and Payment Parameters, from the Federal reinsurance program, less contributions made to the program (referred to as “Premium” in the template).
number
level : Ratio
Projected_Incurred_Claims
The template calculates this value by subtracting the Projected Risk Adjustments, PMPM from the Projected Incurred Claims, before ACA rein & Risk Adj’t, PMPM.
The Allowed Claims PMPM is calculated by the template, and is equal to utilization per 1,000 times average cost per service, divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
Demos
