45 C.F.R. § 153.510

Risk corridors establishment and payment methodology

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(a) General requirement. A QHP issuer must adhere to the requirements set by HHS in this subpart and in the annual HHS notice of benefit and payment parameters for the establishment and administration of a program of risk corridors for calendar years 2014, 2015, and 2016.

(b) HHS payments to health insurance issuers. QHP issuers will receive payment from HHS in the following amounts, under the following circumstances:

(1) When a QHP's allowable costs for any benefit year are more than 103 percent but not more than 108 percent of the target amount, HHS will pay the QHP issuer an amount equal to 50 percent of the allowable costs in excess of 103 percent of the target amount; and

(2) When a QHP's allowable costs for any benefit year are more than 108 percent of the target amount, HHS will pay to the QHP issuer an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of allowable costs in excess of 108 percent of the target amount.

(c) Health insurance issuers' remittance of charges. QHP issuers must remit charges to HHS in the following amounts, under the following circumstances:

(1) If a QHP's allowable costs for any benefit year are less than 97 percent but not less than 92 percent of the target amount, the QHP issuer must remit charges to HHS in an amount equal to 50 percent of the difference between 97 percent of the target amount and the allowable costs; and

(2) When a QHP's allowable costs for any benefit year are less than 92 percent of the target amount, the QHP issuer must remit charges to HHS in an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of the difference between 92 percent of the target amount and the allowable costs.

(d) Charge submission deadline. A QHP issuer must remit charges to HHS within 30 days after notification of such charges.

(e) A QHP issuer is not subject to the provisions of this subpart with respect to a stand-alone dental plan.

(f) Eligibility under health insurance market rules. The provisions of this subpart apply only for plans offered by a QHP issuer in the SHOP or the individual or small group market, as determined according to the employee counting method applicable under State law, that are subject to the following provisions: §§ 147.102, 147.104, 147.106, 147.150, 156.80, and subpart B of part 156 of this subchapter.

(g) Adjustment to risk corridors payments and charges. If an issuer reported a certified estimate of 2014 cost-sharing reductions on its 2014 MLR and Risk Corridors Annual Reporting Form that is lower than the actual value of cost-sharing reductions calculated under § 156.430(c) of this subchapter for the 2014 benefit year, HHS will make an adjustment to the amount of the issuer's 2015 benefit year risk corridors payment or charge measured by the full difference between the certified estimate of 2014 cost-sharing reductions reported and the actual value of cost-sharing reductions provided as calculated under § 156.430(c) for the 2014 benefit year.

[77 FR 17248, Mar. 23, 2012, as amended at 78 FR 15530, Mar. 11, 2013; 78 FR 65094, Oct. 30, 2013; 79 FR 13836, Mar. 11, 2014; 81 FR 12334, Mar. 8, 2016]

Notes of Decisions

Cited in 8 cases, 2016–2018 · leading case: Land of Lincoln Mut. Health Ins. Co. v. United States, 129 Fed. Cl. 81 (Fed. Cl. 2016).

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Land of Lincoln Mut. Health Ins. Co. v. United States, 129 Fed. Cl. 81 (Fed. Cl. 2016). · cites it 17× “§ 18062 ; 45 C.F.R. § 153.510 ; claims for damages based upon alleged breach of an express contract, an implied-in-fact contract, or an implied covenant of good faith and fair dealing; takings claim OPINION AND ORDER LETTOW, Judge.”

Moda Health Plan, Inc. v. United States, 892 F.3d 1311 (Fed. Cir. 2018). · cites it 4× “45 C.F.R. § 153.510 (b). The regulations similarly provided that insurers “must remit charges to HHS” according to the statutory formula for payments in.”

Blue Cross & Blue Shield of North Carolina v. United States, 131 Fed. Cl. 457 (Fed. Cl. 2017). · cites it 13× “First, Blue Cross alleges that the government violated Section 1342 of the ACA and its implementing regulations, 45 C.F.R. § 153.510 , by failing to make full, annual Risk Corridors Program Payments to Blue Cross.”

Moda Health Plan, Inc. v. United States, 130 Fed. Cl. 436 (Fed. Cl. 2017). · cites it 4× “23, 2012) (codified at 45 C.F.R. § 153.510 ). In another rule it released that day, HHS added, “A QHP issuer must submit to HHS data on the premiums earned with respect to each QHP that the issuer offers in the manner and timeframe set forth in the annual HHS notice of benefit…”

Health Repub. Ins. Co. v. United States, 129 Fed. Cl. 757 (Fed. Cl. 2017). · cites it 4× “Thus, the final regulation establishing the risk corridors and describing the payment methodology, 45 C.F.R. § 153.510 , provided only: (a) General requirement.”

Maine Cmty. Health Options v. United States, 133 Fed. Cl. 1 (Fed. Cl. 2017). · cites it 2× “45 C.F.R. § 153.510 (2012); 78 Fed. Reg. 15,410 , 15,631 (Mar.”

Gerhart v. United States Dep't of Health & Human Servs., 242 F. Supp. 3d 806 (S.D. Iowa 2017). · cites it 2× “§ 18062 (b)(1) (providing HHS “shall pay” specified amounts to eligible issuers of qualified health plans); 45 C.F.R. § 153.510 (b) (providing HHS “will pay” specified amounts to eligible issuers of qualified health plans).”

Molina Healthcare of California, Inc. v. United States, 133 Fed. Cl. 14 (Fed. Cl. 2017). “First, the rule added the following subsection to 45 C.F.R. § 153.510 : “(d) Charge submission deadline.”

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