Rate Review Training

Rate Review Training

Technical FAQs - Set 1

CCIIO has provided training to issuers and States on the new rate review requirements.  This page contains answers to questions that CCIIO has received through the training process.

Table of Contents

Rate Review Training Webinars and Registration Information

1. Should all States participate in the rate review training?
All States are strongly encouraged to participate in the rate review webinars prior to the September 1, 2011, start date of the Rate Review Program.  The training provides all States with information about accessing rate review data submitted by issuers for use in their States via the Health Insurance Oversight System (HIOS).  Additionally, the training includes procedures and requirements for entering State rate review determinations in the HIOS system.

2. Do issuers need to take the training now if they do not anticipate having any rate increases above the subject to review threshold in 2011?
The new federal rate review reporting requirements take effect on September 1, 2011.  Issuers offering products in the individual and small group markets should take the training prior to this date to ensure compliance with the new reporting requirements.  Additionally, CMS is conducting ongoing user group calls with issuers in August and September.  By taking the training now, issuers will have the opportunity to follow up with CMS via the user group calls on any questions about the program
The webinar trainings will remain posted on the CMS training portal after September 1st to give issuers access to the webinars as a reference after the start date of the program.

3. Which issuer or State staff should take the training?
There are no restrictions on the type of issuer or State staff that may take the training, and there is no requirement that staff taking the training must be registered HIOS users.  Both the issuer and State trainings provide an overview of the rate review program, including important information on program policies and reporting requirements.  This information may be useful to a wide range of staff, including those not registered in HIOS.

4. If an issuer or State has multiple people who want to take the webinar training, do they have to register individually?
Yes, each person, including contractors, must register individually for the webinar training by going to following links:
Issuer Training: https://webinar.cms.hhs.gov/ratereviewissuers/event/registration.html - Opens in a new window
State Training: https://webinar.cms.hhs.gov/ratereviewstates/event/registration.html - Opens in a new window

5. May actuarial contractors register for HIOS and/or the webinar training?
Yes, actuarial contractors may register for both HIOS and the webinar training if they are working on rate review matters with a health insurance issuer or State regulator.  If contractors wish to register for HIOS, the issuer or State regulator must register on the contractor’s behalf by adding the contractor to the list of HIOS registrants it sends to CMS.  If contractors wish to register for the webinar training, contractors must register themselves via one of the training registration links above.
When registering for the webinar training, contractors must respond to the contractor questions on the registration page.  These questions require contractors to confirm they are under contract with an issuer or State, and to provide contact information (name, address, and email address) for the issuer or State for verification purposes.

6. What if I register for the wrong training by mistake or decide not to take the training after I register?
After you register for the training, there is no requirement that you actually complete the training, and you are not required to notify CMS that you are not taking the training. Once registered, you may view any of the training webinars available for issuers or State regulators, so you don’t need to be concerned about registering for the “wrong” training.

User Group Calls

7. What is the format of the User Group Calls?
During the User Group Calls, CMS staff will answer questions emailed to RateReview@hhs.gov that were received throughout the week, and also will answer questions in real time that are emailed to RateReview@hhs.gov during the calls.  CMS encourages issuers and States to email questions to RateReview@hhs.gov well in advance of the User Group Calls to allow CMS to formulate a thorough response. CMS requests that the email identify the call (date and time) on which the questioner would like CMS to answer the question.
Issuers and States are not required to listen to the User Group Calls.  The User Group Calls are intended to supplement the webinar training by addressing rate review questions submitted to CMS via email before and during the calls.  CMS will not use the User Group Calls to present new training material.

8. Will CMS post a transcript or audio link of the User Group Calls?
CMS will periodically post Frequently Asked Questions (FAQs) that include the questions addressed during the User Group Calls.  The FAQs will be posted on CMS’ website at: http://cms.gov/cciio/programs/marketreforms/rates/index.html


9. What are the differences between the issuer submitter and attester roles in HIOS?
Only a submitter may submit a new Preliminary Justification record in HIOS and only an attester may attest to a submitted Preliminary Justification record in HIOS.  A single HIOS user may be registered as both a submitter and attester.  Companies may make these designations at their own discretion and may assign multiple users for both roles.
In addition to submitting and attesting to Preliminary Justification records in HIOS, issuers may also have to amend attested records (e.g., if they modify a rate increase while a review is in progress, or if CMS requests supplemental information).  Attesters and submitters have the same access to all of the post-attestation functions in HIOS, so either designation may amend attested records.  Additionally, both user types receive the same email notifications on each record.
Note that all State users have the same HIOS access rights.  States are not required to designate an attester or submitter.

10. Is the initial submission of the Preliminary Justification the only type of HIOS submission that requires attestation?
Yes. Issuers are only required to submit the Preliminary Justification once for each rate increase, regardless of whether the rate increase changes during the review process.  This initial submission of the Preliminary Justification is the only action that requires attestation in HIOS.  None of the other follow-up actions (e.g., supplemental material submissions, rate modifications) for submitted records require attestation.

11. Do issuers have to use their existing Plan Finder submitters and attesters for the submission of rate review reporting in HIOS?
No.  Issuers may assign different users to these roles in the HIOS rate review module.  Note that existing HIOS users still have to register for access to the rate review module.

12. Should issuers include HIOS issuer IDs in the organization field of the registration request?
Yes. If issuers have HIOS IDs they should include them.  This information will help with processing the registration request.

13. Can a single registration request include more than one HIOS issuer ID?
Yes, registration requests may be made for multiple HIOS issuer IDs to be assigned to a single user.  In the registration request, issuers should specify the HIOS issuer IDs that should be assigned to each HIOS user.  Users with access to multiple issuer IDs will not need a separate user ID for each issuer.

14. When will registered HIOS users receive their login information?
CMS is currently reviewing and approving user requests.  All approved users will receive an email with their login information immediately before the September 1st effective date of the rate review program.  No users will be permitted to access or enter data in the rate review system prior to the start of the program.

15. Can issuers make changes to their HIOS registration requests after they have been submitted to CMS?
Yes, issuers can make changes to their registration requests.  Issuers should submit a new Excel worksheet with the revised information on all of their requested HIOS users.  (This second submission will take the place of the first Excel submission.)  Issuers should note in the email that they are resubmitting their request.

16. How does the email notification process work in HIOS?
State users will receive notification emails each time an issuer attests to a record in HIOS for a rate increase to be implemented in their State.  Issuer users will receive a submission status email following the submission of each record (the email will indicate whether the submission passed or failed the automated validation checks).  For CMS reviews, issuers will receive an email notification if CMS needs additional information to conduct its review (this is referred to in HIOS as a “request for supplemental materials”).  Lastly, when a rate review determination is made by either a State or CMS, issuers will receive an email notification of the determination.  All issuer emails are sent to submitter and attester users.

17. What types of information will a State have access to in HIOS if CMS is conducting some or all of its reviews?
States will have access to all Preliminary Justification submissions in HIOS, regardless of whether the review is being conducted by the State or CMS.   However, the HIOS function that allows States to enter a rate review determination are only enabled if the review is being conducted by the State.

Issuer Reporting Requirements

18.What are the HIOS product IDs that were referenced in the webinar?
A HIOS ID is assigned to each product that is registered in HIOS. The rate review module is populated with existing HIOS products and issuers may only submit rate review information for a product that is currently listed in HIOS.  Issuers should contact CMS (ratereview@hhs.gov) if they identify a product that meets the rate review reporting requirements but is not currently listed in the HIOS rate review module.

19.What is the distinction between the terms “plan” and “product” for the purposes of the rate review reporting requirements?
The rate review regulation defines the term “product” as a package of health insurance coverage benefits with a discrete set of rating and pricing methodologies that a health insurance issuer offers in a State.  A product may have numerous plans with different premium and cost sharing structures.  The Preliminary Justification is reported at the product level; thus, all information in the Preliminary Justification must be aggregated to the product level. (As discussed in the next question, products may be aggregated under some conditions.)
The definition of “product” in the rate review program tracks with the definition of “product” used in the HIOS Plan Finder.  In practice, issuers will locate and report on products in HIOS using the product IDs that have already been entered into the system via the HIOS Plan Finder module.

20.Healthcare.gov does not include information on closed block products.  Do we have to submit rate review information on these products in HIOS?
Yes, the rate review reporting requirements apply to closed block products and issuers must submit information on closed block rate increases in HIOS.  While no information on closed block products is available on Healthcare.gov, HIOS does contain product IDs for closed block products.

21.Currently no information is collected in HIOS on products offered in the U.S. Territories. Do issuers have to report on these products?
Yes, the rate review requirements do apply to products offered in the U.S. Territories.  In order to accommodate reporting of these products, issuers will be required to submit information on Territory products during the August Plan Finder reporting window. CMS will provide additional guidance regarding the information that issuers must provide on these products. Please note that when CMS refers to the term “State” as it concerns rate review, it includes Territories unless otherwise specified.

22.What is the definition of small group market in the rate review program?  
At this time, the rate review program follows existing State definitions for the small group market.

23.To what type of products do the rate review reporting requirements apply?
The rate review reporting requirements apply to individual and small group products offered by health insurance issuers.  The requirements do not apply to grandfathered products as defined in 45 C.F.R. § 147.140, or to excepted benefits as described in Public Health Service Act section 2791(c).
The rate review reporting requirements do not apply to Medicare and Medicaid products, such as Part C and D products, Medicaid managed care products, or Medicare supplemental products.

Preliminary Justification

24.When will the Excel file for Part I of the Preliminary Justification be available?
The Preliminary Justification is still pending Paperwork Reduction Act (PRA) approval.  Currently the CMS CCIIO website has a link to the PDF version of Part I at http://cms.gov/cciio/resources/other/index.html#rir . The version posted was released on 5/27/11 for public comment. CMS will post the final Excel version of Part I as soon as the PRA approval process is complete.

25.How should issuers address concerns or questions about specific data elements contained on the Preliminary Justification?
Issuers should submit their questions or concerns about the Preliminary Justification to ratereview@hhs.gov.  These questions will be addressed on the ongoing user group calls and responses will be included in updated versions of the FAQ.

26.In the event that no rate increases are anticipated, is a filing still required?
No.  A HIOS Preliminary Justification submission is not required if there is not a rate increase, or if a rate increase is not subject to review.

27.Section C of Part 1 of the Preliminary Justification includes the following items:
1. Projected net claims
2. Administrative costs
3. Underwritting gain/loss
4. Total rate
For individual carriers that hold contract reserves, where should the contract reserves be included in the categories above?

Contract reserves should be included in the “Projected net claims” category of the Preliminary Justification, Section C, Part 1.  Furthermore, the more detailed rate filing must break out contract reserves and justify them (reason for holding, tabular basis, etc.).

28.How should issuers include contract reserves in the projected net claims when the claims are projected from Section A with no category for contract reserves?
The contract reserves should be allocated over the Part A net claim costs in proportion to the level of the claims by provider before contract reserves are added.

29.When will the 10% Threshold calculation training module be available?
CMS posted the webinar training module on August 12th.  The training was posted with the other issuer training modules currently posted on CMS’ training webpage.

State Requirements

30.When States provide links on their websites to the Preliminary Justification for a particular filing, should the link take the consumer to the posting for that particular filing, or to the main Healthcare.gov webpage?
Under effective rate review program requirements, States must post on their websites, information on each proposed increase that is subject to review.    CMS previously advised States that they could comply with this requirement by linking to each rate filing’s corresponding consumer disclosure on HealthCare.gov (which contains Parts I and II of the Preliminary Justification in a consumer-friendly format).  To make it easier for States to comply with this web-posting requirement, it is acceptable for a State to provide a hyperlink to the State’s rate filing search result page on http://companyprofiles.healthcare.gov/ - Opens in a new window .  We are aware that some States are linking to the main HealthCare.gov company profile search page instead of the State-specific search result page.  It is not sufficient to link to the main search page; the link must go to the State’s search result page that lists all rate filings (and corresponding consumer disclosures) for the State.

In addition, States may continue to provide a hyperlink to the particular consumer disclosure on HealthCare.gov for each rate filing under review.  To assist States in providing the consumer disclosure hyperlinks, we created a new report in HIOS with a listing of records posted on HealthCare.gov.  The new report labeled “Rate Review Records on HealthCare.gov” has been added to the Announcements page for State HIOS users. This report provides the links to all rate review records that are posted for a respective State on Healthcare.gov (it is updated in real time as new records are posted to HealthCare.gov).  The report is provided in XML format, so that States can use their reports to create automated processes for updating the rate review information on their websites.  States should consult with their website development staff to get the maximum benefit from this feature.

If you have about any questions about the web-posting requirement or the new HIOS enhancement, please email us at RateReview@hhs.gov.

31.Will CMS provide a template for the description of the rate review findings that States must include with each rate review determination submitted in HIOS?
This description will be posted with the filing record on Healthcare.gov and is primarily intended to provide consumers with information about the review process and determination.  CMS did not provide a template as we do not want to prescribe how States explain their review findings to consumers.  However, the State Rate Review Manual contains a set of guidelines that States may consult when they are preparing the explanation of their review.

Technical Questions Related to Filings 

32.Pooling of products: A company has in its small group line of business four products: A, B, C and D.  The experience for the four products is pooled to get a rate increase for the pool.  There is another process that sets the benefit relativities between products.  This means annual average rate increases for each product can be different from both other products and the pool.  For example, one might see:
-A pool increase of 12%
-An annual product increases after a change in benefit relativity: Product A increases 14%, Product B increases 10%, Product C increases 11%, and Product D increases 13%
Would this company be required to submit one Preliminary Justification at the 12% level or four Preliminary Justifications (one for each product)?

Since the rate increases are different on each of the four products, four different Preliminary Justifications are needed, one for each of the four products.

33.Some carriers have had historical experience that justifies assuming trend factors much greater than those for most of the other carriers, resulting in requested increases greater than 10%.  The carrier is aware that its experience is unusual and is investigating, but does not yet have an explanation.  Should the requested increase be considered reasonable?
State law and State standards as to what is unreasonable or not unreasonable should continue to be applied in States that have effective rate review programs.  In States where CMS is performing the review, the standard used to make an unreasonable determination is the three-pronged excessive, unjustified, and unfairly discriminatory standard, as articulated in the federal rate review regulation. States with an effective rate review program should continue to apply their standard using all the facts of the case.

34.A carrier has consistently filed significant rate increases on a block of business over several years.  As a result of this history, the healthy insureds have tended to terminate their coverage leaving the unhealthy insureds trapped in a "death spiral."  The current large increase is seemingly justified based on recent historical loss ratios.  Should the requested increase be considered reasonable?
The answer is the same as the preceding question.  State law and State standards as to what is unreasonable or not unreasonable should be applied in States that have effective rate review programs.    In States where CMS is performing the review, the standard used to make an unreasonable determination is the three-pronged excessive, unjustified, and unfairly discriminatory standard, as articulated in the federal rate review regulation.

35.Does the 10% rate increase threshold that triggers review apply only to the weighted average increase or are minimum and maximum increases considered as well?
The threshold test trigger uses the weighted average premium rate increase to determine if a given increase is subject to review.  The maximum increase and minimum increase are not used in the threshold test.

36.The final regulation requires issuers to file a Preliminary Justification at the product level.  Some States focus their review at the filing level.  Thus, States may review multiple Preliminary Justifications per rate filing.  How does CMS envision the State's review process to operate in this case?
If a filing includes more than one product, a State with an effective review process should conduct the review of the filing in the manner in which it normally conducts such reviews. The regulation should not cause any State with an effective rate review program to change the manner in which it reviews rate filings.  However, a separate result will have to be entered for each Preliminary Justification record that appears in the HIOS system.
In the case where a filing contains several products that are pooled for one Preliminary Justification submission, the result of the review would be entered into the HIOS system just one time for the pooled record.

37.Would the determination for all Preliminary Justifications described in item 36 be identical?
The determination for each product need not be identical.

38.Would there ever be a case in which different products within one rate filing received different determinations?
Yes, it is conceivable that the same proposed rate increase would be unreasonable for one product in the filing and not unreasonable for another.

39.Does CMS have guidance in the event of the situation described in item 38?
CMS does not have additional guidance at this time.  States with effective rate review programs should follow their State law and State standards in making any determination as to whether a particular product increase is unreasonable or not.

40.There is a group health insurance carrier in a State which does not have an effective rate review process.  The carrier’s rates are effective 10/1/2011, but renewal notices will go out to members beginning on 8/1/2011.
Does the Carrier have to file with CMS before “implementation” of the rates?  Is implementation the date the renewal letters go out, or the effective date of the rate increase?

Yes.  For States with a filing requirement, filings submitted on or after September 1, 2011 are subject to the rate review regulation.   For States where there is no filing requirement (i.e, no effective rate review program), increases with an effective date on or after September 1, 2011 are subject to the rate review regulation and must file all three parts of the Preliminary Justification with CMS.
The implementation date is the effective date of the rate increase.  The renewal letter has no bearing on the timing of the Preliminary Justification submission to CMS.

41.If a filing includes a requested rate increases of 7%, 12% and 14% for three different products, how many preliminary justifications would be required for this filing?  
The most granular level of submission for the Preliminary Justification is the product level.   Two or more products can be submitted together in one “pooled” Preliminary Justification submission if the product’s experience is combined or pooled for the purposes of rate making AND the products submitted together have the same increase.   If the experience for two or more products was not combined or pooled for rate making purposes, a Preliminary Justification must be submitted for each product.

42.For the same filing mentioned in item 41 above, rather than 3 different increases, the filer decided to request the same increase of 11% for all 3 products, and the increase was based on the combined experience of the products.  In this case, would the filer be required to submit just one preliminary justification?  
The filer may combine the three products into one Preliminary Justification, but is not required to do so.

43.For the same filing mentioned in item 41 above, the filer pooled the experience from all three products but decided to allocate different increases to each product.  The total of all the increases was equivalent to the overall increase based on the combined experience.  Would you consider the increases unreasonable?   
State law and State standards as to what is unreasonable or not unreasonable should continue to be applied in States that have effective rate review programs.  In States where CMS is performing the review, the standard used to make an unreasonable determination is the three-pronged excessive, unjustified, and unfairly discriminatory standard, as articulated in the federal rate review regulation.

Page Last Modified:
09/06/2023 05:05 PM