45 C.F.R. § 153.530

Risk corridors data requirements

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(a) Premium data. A QHP issuer must submit to HHS data on the premiums earned with respect to each QHP that the issuer offers in a manner specified by HHS.

(b) Allowable costs. A QHP issuer must submit to HHS data on the allowable costs incurred with respect to the QHP issuer's non-grandfathered health plans in a market within a State in a manner specified by HHS. For purposes of this subpart, allowable costs must be —

(1) Increased by any risk adjustment charges paid by the issuer for the non-grandfathered health plans under the risk adjustment program established under subpart D of this part.

(2) Reduced by —

(i) Any risk adjustment payments received by the issuer for the non-grandfathered health plans under the risk adjustment program established pursuant to subpart D of this part;

(ii) Any reinsurance payments received by the issuer for the non-grandfathered health plans under the transitional reinsurance program established under subpart C of this part;

(iii) A cost-sharing reduction amount equal to the amount of cost-sharing reductions for the benefit year as calculated under § 156.430(c) of this subchapter, to the extent not reimbursed to the provider furnishing the item or service.

(iv) For the 2015 and 2016 benefit years, any difference between—

(A) The sum of unpaid claims reserves and claims incurred but not reported, as set forth in §§ 158.103 and 158.140(a)(2) and (3) of this subchapter, that were reported on the MLR and Risk Corridors Annual Reporting Form for the year preceding the benefit year; and

(B) The actual claims incurred during the year preceding the benefit year and paid between March 31 of the benefit year and March 31 of the year following the benefit year.

(c) Allowable administrative costs. A QHP issuer must submit to HHS data on the allowable administrative costs incurred with respect to the QHP issuer's non-grandfathered health plans in a market within a State in a manner specified by HHS.

(d) Timeframes. For each benefit year, a QHP issuer must submit all information required under paragraphs (a) through (c) of this section by July 31 of the year following the benefit year.

(e) Requirement to submit enrollment data for risk corridors adjustment. A health insurance issuer in the individual or small group market of a transitional State must submit, in a manner and timeframe specified by HHS, the following:

(1) A count of its total enrollment in the individual market and small group market; and

(2) A count of its total enrollment in individual market and small group market policies that meet the criteria for transitional policies outlined in the CMS letter dated November 14, 2013.

[77 FR 17248, Mar. 23, 2012, as amended at 78 FR 15531, Mar. 11, 2013; 78 FR 65094, Oct. 30, 2013; 79 FR 13836, Mar. 11, 2014; 79 FR 37662, July 2, 2014; 81 FR 12334, Mar. 8, 2016]

Notes of Decisions

Cited in 6 cases, 2016–2018 · leading case: Moda Health Plan, Inc. v. United States, 892 F.3d 1311 (Fed. Cir. 2018).

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Moda Health Plan, Inc. v. United States, 892 F.3d 1311 (Fed. Cir. 2018). · cites it 2× “at 15,530–31 (codified at 45 C.F.R. § 153.530 ). The parameters also provided that an issuer of a plan in an exchange must submit all information required for calculating risk corri- dors payments by July 31 of the year following the benefit year.”

Health Repub. Ins. Co. v. United States, 129 Fed. Cl. 757 (Fed. Cl. 2017). · cites it 2× “” (codified at 45 C.F.R. § 153.530 (a) (2012))). The notice of benefit and payment parameters mentioned in the Premium Stabilization Rule was published as a proposed rule by the Centei’s for Medicare and Medicaid Services (“CMS”), an agency of HHS, on December 7, 2012.”

Land of Lincoln Mut. Health Ins. Co. v. United States, 129 Fed. Cl. 81 (Fed. Cl. 2016). “’s Reply at 4, but those aspects concern HHS’s requirement that qualified health plans must submit data to HHS annually, see 45 C.F.R. § 153.530 (d), and must be certified annually, see 45 C.”

Molina Healthcare of California, Inc. v. United States, 133 Fed. Cl. 14 (Fed. Cl. 2017). · cites it 2× “23, 2012) (codified at 45 C.F.R. § 153.530 (a)). In the same publication, HHS released an impact analysis of its proposed rules in which it cited the findings of the Congressional Budget Office (“CBO”).”

Moda Health Plan, Inc. v. United States, 130 Fed. Cl. 436 (Fed. Cl. 2017). “23, 2012) (codified at 45 C.F.R. § 153.530 (a)). In the same publication, HHS also released an impact analysis of its proposed rules in which it cited the findings of the Congressional Budget Office.”

Blue Cross & Blue Shield of North Carolina v. United States, 131 Fed. Cl. 457 (Fed. Cl. 2017). · cites it 2× “45 C.F.R. § 153.530 (a)-(d). HHS uses Ríe data provided to calculate the charges and payments due to, and from, each issuer for the preceding benefit year under the Risk Corridors Program.”

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