Title 45

PART 158

Part 158 - Issuer Use Of Premium Revenue: Reporting And Rebate Requirements

PART 158 - ISSUER USE OF PREMIUM REVENUE: REPORTING AND REBATE REQUIREMENTS Authority:42 U.S.C. 300gg-18. Source:75 FR 74921, Dec. 1, 2010, unless otherwise noted.

45:2.0.1.1.16.0.1.1SECTION 158.101
   158.101 Basis and scope.
45:2.0.1.1.16.0.1.2SECTION 158.102
   158.102 Applicability.
45:2.0.1.1.16.0.1.3SECTION 158.103
   158.103 Definitions.
45:2.0.1.1.16.1SUBPART A
Subpart A - Disclosure and Reporting
45:2.0.1.1.16.1.1.1SECTION 158.110
   158.110 Reporting requirements related to premiums and expenditures.
45:2.0.1.1.16.1.1.2SECTION 158.120
   158.120 Aggregate reporting.
45:2.0.1.1.16.1.1.3SECTION 158.121
   158.121 Newer experience.
45:2.0.1.1.16.1.1.4SECTION 158.130
   158.130 Premium revenue.
45:2.0.1.1.16.1.1.5SECTION 158.140
   158.140 Reimbursement for clinical services provided to enrollees.
45:2.0.1.1.16.1.1.6SECTION 158.150
   158.150 Activities that improve health care quality.
45:2.0.1.1.16.1.1.7SECTION 158.151
   158.151 Expenditures related to Health Information Technology and meaningful use requirements.
45:2.0.1.1.16.1.1.8SECTION 158.160
   158.160 Other non-claims costs.
45:2.0.1.1.16.1.1.9SECTION 158.161
   158.161 Reporting of Federal and State licensing and regulatory fees.
45:2.0.1.1.16.1.1.10SECTION 158.162
   158.162 Reporting of Federal and State taxes.
45:2.0.1.1.16.1.1.11SECTION 158.170
   158.170 Allocation of expenses.
45:2.0.1.1.16.2SUBPART B
Subpart B - Calculating and Providing the Rebate
45:2.0.1.1.16.2.1.1SECTION 158.210
   158.210 Minimum medical loss ratio.
45:2.0.1.1.16.2.1.2SECTION 158.211
   158.211 Requirement in States with a higher medical loss ratio.
45:2.0.1.1.16.2.1.3SECTION 158.220
   158.220 Aggregation of data in calculating an issuer's medical loss ratio.
45:2.0.1.1.16.2.1.4SECTION 158.221
   158.221 Formula for calculating an issuer's medical loss ratio.
45:2.0.1.1.16.2.1.5SECTION 158.230
   158.230 Credibility adjustment.
45:2.0.1.1.16.2.1.6SECTION 158.231
   158.231 Life-years used to determine credible experience.
45:2.0.1.1.16.2.1.7SECTION 158.232
   158.232 Calculating the credibility adjustment.
45:2.0.1.1.16.2.1.8SECTION 158.240
   158.240 Rebating premium if the applicable medical loss ratio standard is not met.
45:2.0.1.1.16.2.1.9SECTION 158.241
   158.241 Form of rebate.
45:2.0.1.1.16.2.1.10SECTION 158.242
   158.242 Recipients of rebates.
45:2.0.1.1.16.2.1.11SECTION 158.243
   158.243 De minimis rebates.
45:2.0.1.1.16.2.1.12SECTION 158.244
   158.244 Unclaimed rebates.
45:2.0.1.1.16.2.1.13SECTION 158.250
   158.250 Notice of rebates.
45:2.0.1.1.16.2.1.14SECTION 158.251
   158.251 Notice of MLR information.
45:2.0.1.1.16.2.1.15SECTION 158.260
   158.260 Reporting of rebates.
45:2.0.1.1.16.2.1.16SECTION 158.270
   158.270 Effect of rebate payments on solvency.
45:2.0.1.1.16.3SUBPART C
Subpart C - Potential Adjustment to the MLR for a State's Individual Market
45:2.0.1.1.16.3.1.1SECTION 158.301
   158.301 Standard for adjustment to the medical loss ratio.
45:2.0.1.1.16.3.1.2SECTION 158.310
   158.310 Who may request adjustment to the medical loss ratio.
45:2.0.1.1.16.3.1.3SECTION 158.311
   158.311 Duration of adjustment to the medical loss ratio.
45:2.0.1.1.16.3.1.4SECTION 158.320
   158.320 Information supporting a request for adjustment to the medical loss ratio.
45:2.0.1.1.16.3.1.5SECTION 158.321
   158.321 Information regarding the State's individual health insurance market.
45:2.0.1.1.16.3.1.6SECTION 158.322
   158.322 Proposal for adjusted medical loss ratio.
45:2.0.1.1.16.3.1.7SECTION 158.323
   158.323 State contact information.
45:2.0.1.1.16.3.1.8SECTION 158.330
   158.330 Criteria for assessing request for adjustment to the medical loss ratio.
45:2.0.1.1.16.3.1.9SECTION 158.340
   158.340 Process for submitting request for adjustment to the medical loss ratio.
45:2.0.1.1.16.3.1.10SECTION 158.341
   158.341 Treatment as a public document.
45:2.0.1.1.16.3.1.11SECTION 158.342
   158.342 Invitation for public comments.
45:2.0.1.1.16.3.1.12SECTION 158.343
   158.343 Optional State hearing.
45:2.0.1.1.16.3.1.13SECTION 158.344
   158.344 Secretary's discretion to hold a hearing.
45:2.0.1.1.16.3.1.14SECTION 158.345
   158.345 Determination on a State's request for adjustment to the medical loss ratio.
45:2.0.1.1.16.3.1.15SECTION 158.346
   158.346 Request for reconsideration.
45:2.0.1.1.16.3.1.16SECTION 158.350
   158.350 Subsequent requests for adjustment to the medical loss ratio.
45:2.0.1.1.16.4SUBPART D
Subpart D - HHS Enforcement
45:2.0.1.1.16.4.1.1SECTION 158.401
   158.401 HHS enforcement.
45:2.0.1.1.16.4.1.2SECTION 158.402
   158.402 Audits.
45:2.0.1.1.16.4.1.3SECTION 158.403
   158.403 Circumstances in which a State is conducting audits of issuers.
45:2.0.1.1.16.5SUBPART E
Subpart E - Additional Requirements on Issuers
45:2.0.1.1.16.5.1.1SECTION 158.501
   158.501 Access to facilities and records.
45:2.0.1.1.16.5.1.2SECTION 158.502
   158.502 Maintenance of records.
45:2.0.1.1.16.6SUBPART F
Subpart F - Federal Civil Penalties
45:2.0.1.1.16.6.1.1SECTION 158.601
   158.601 General rule regarding the imposition of civil penalties.
45:2.0.1.1.16.6.1.2SECTION 158.602
   158.602 Basis for imposing civil penalties.
45:2.0.1.1.16.6.1.3SECTION 158.603
   158.603 Notice to responsible entities.
45:2.0.1.1.16.6.1.4SECTION 158.604
   158.604 Request for extension.
45:2.0.1.1.16.6.1.5SECTION 158.605
   158.605 Responses to allegations of noncompliance.
45:2.0.1.1.16.6.1.6SECTION 158.606
   158.606 Amount of penalty - general.
45:2.0.1.1.16.6.1.7SECTION 158.607
   158.607 Factors HHS uses to determine the amount of penalty.
45:2.0.1.1.16.6.1.8SECTION 158.608
   158.608 Determining the amount of the penalty - mitigating circumstances.
45:2.0.1.1.16.6.1.9SECTION 158.609
   158.609 Determining the amount of penalty - aggravating circumstances.
45:2.0.1.1.16.6.1.10SECTION 158.610
   158.610 Determining the amount of penalty - other matters as justice may require.
45:2.0.1.1.16.6.1.11SECTION 158.611
   158.611 Settlement authority.
45:2.0.1.1.16.6.1.12SECTION 158.612
   158.612 Limitations on penalties.
45:2.0.1.1.16.6.1.13SECTION 158.613
   158.613 Notice of proposed penalty.
45:2.0.1.1.16.6.1.14SECTION 158.614
   158.614 Appeal of proposed penalty.
45:2.0.1.1.16.6.1.15SECTION 158.615
   158.615 Failure to request a hearing.