| (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(3) the rate filing has been withdrawn.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:
(1) the URRT (Part I);
(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:
(i) catastrophic plans;
(ii) bronze plans;
(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%;
(iv) gold plans; and
(v) platinum plans;
(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;
(C) earned premium; and
(D) member months.
(2) For current year cumulative data through March
31, an issuer must submit:
(A) earned premium;
(B) member months; and
(C) the enrollment spreadsheet required under subsection
(f)(5) of this section.
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