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Federal Register / Vol. 86, No. 124 / Thursday, July 1, 2021 / Proposed Rules on a substantial number of small entities.
In addition, section 1102b of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102b of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan statistical area and has fewer than 100 beds. While this rule is not subject to section 1102 of the Act, we have determined that this proposed rule would not affect small rural hospitals. Therefore, the Secretary has determined that this rule would not have a significant impact on the operations of a substantial number of small rural hospitals.

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F. Unfunded Mandates Reform Act UMRA
Section 202 of the Unfunded Mandates Reform Act of 1995 UMRA
also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2021, that threshold is approximately $158
million. Although we have not been able to quantify all costs, we expect the combined impact on state, local, or Tribal governments and the private sector to be below the threshold.
G. Federalism Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule and subsequent final rule that imposes substantial direct requirement costs on state and local governments, preempts state law, or otherwise has federalism implications.
In our view, while this proposed rule would not impose substantial direct requirement costs on state and local governments, this regulation has federalism implications due to potential direct effects on the distribution of power and responsibilities among the state and federal governments relating to determining standards relating to health insurance that is offered in the individual and small group markets.
In compliance with the requirement of Executive Order 13132 that agencies examine closely any policies that may have federalism implications or limit the policy making discretion of the states, we have engaged in efforts to consult with and work cooperatively with affected states, including participating in conference calls with
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and attending conferences of the NAIC, and consulting with state insurance officials on an individual basis.
While developing this rule, we attempted to balance the states interests in regulating health insurance issuers with the need to ensure market stability.
By doing so, we complied with the requirements of Executive Order 13132.
Because states have flexibility in designing their Exchange and Exchangerelated programs, state decisions will ultimately influence both administrative expenses and overall premiums. States are not required to establish an Exchange. For states that elected previously to operate an Exchange, those states had the opportunity to use funds under Exchange Planning and Establishment Grants to fund the development of data. Accordingly, some of the initial cost of creating programs was funded by Exchange Planning and Establishment Grants. After establishment, Exchanges must be financially self-sustaining, with revenue sources at the discretion of the state. A
user fee is assessed on issuers under all existing Exchange models, including State Exchanges where the user fee is assessed by the state, SBEFPs, and the FFEs. We have solicited comment on the proposed user fee rate of 2.75
percent of monthly premiums for issuers in FFEs and 2.25 percent of monthly premiums for issuers in SBE
FPs.
H. Congressional Review Act This proposed rule is subject to the Congressional Review Act provisions of the Small Business Regulatory Enforcement Fairness Act of 1996 5
U.S.C. 801, et seq., which specifies that before a rule can take effect, the federal agency promulgating the rule shall submit to each House of the Congress and to the Comptroller General a report containing a copy of the rule along with other specified information, and has been transmitted to the Congress and the Comptroller for review. This proposed rule, if finalized as proposed, is expected to be a major rule as that term is defined in 5 U.S.C. 8042, because it is likely to result in an annual effect on the economy of $100 million or more.
List of Subjects Health care, Health insurance, Reporting and recordkeeping requirements.
45 CFR Part 147

Fmt 4701

Administrative practice and procedure, Advertising, Age discrimination, Brokers, Civil rights, Citizenship and naturalization, Conflict of interests, Consumer protection, Grant programs-health, Grants administration, Health care, Health insurance, Health maintenance organizations HMO, Health records, Hospitals, Indians, Individuals with disabilities, Intergovernmental relations, Loan programs-health, Medicaid, Organization and functions Government agencies, Public assistance programs, Reporting and recordkeeping requirements, Sex discrimination, State and local governments, Technical assistance, Taxes, Women, Youth.
45 CFR Part 156
Administrative practice and procedure, Advertising, Advisory committees, Age discrimination, Alaska, Brokers, Citizenship and naturalization, Civil rights, Conflict of interests, Consumer protection, Grant programshealth, Grants administration, Health care, Health insurance, Health maintenance organization HMO, Health records, Hospitals, Indians, Individuals with disabilities, Intergovernmental relations, Loan programs-health, Medicaid, Organization and functions Government agencies, Prescription drugs, Public assistance programs, Reporting and recordkeeping requirements, Sex discrimination, State and local governments, Sunshine Act, Technical assistance, Women, Youth.
For the reasons set forth in the preamble, the Department of the Treasury proposes to amend 31 CFR
subtitle A as set forth below:
PART 33WAIVERS FOR STATE
INNOVATION
1. The authority citation for part 33
continues to read as follows:

Authority: Sec. 1332, Pub. L. 111148, 124
Stat. 119.

2. Amend 33.108 by revising paragraphs f3iv introductory text and f3ivA through C to read as follows:

33.108

Age discrimination, Citizenship and naturalization, Civil rights, Health care,
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45 CFR Part 155

31 CFR Part 33

PO 00000

Health insurance, Individuals with disabilities, Intergovernmental relations, Reporting and recordkeeping requirements, Sex discrimination.

Sfmt 4702

Application procedures.

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