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Federal Register / Vol. 86, No. 127 / Wednesday, July 7, 2021 / Rules and Regulations
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to calculate the prospective payment for the first and subsequent quarters of program operation until the state provides us with actual enrollment data for those periods. The actual enrollment data is required to calculate the final BHP payment amount and make any necessary reconciliation adjustments to the prior quarters prospective payment amounts due to differences between projected and actual enrollment.
Subsequent quarterly deposits to the states trust fund will be based on the most recent actual enrollment data submitted to us. Actual enrollment data must be based on individuals enrolled for the quarter who the state found eligible and whose eligibility was verified using eligibility and verification requirements as agreed to by the state in its applicable BHP Blueprint for the quarter that enrollment data is submitted. Procedures will ensure that federal payments to a state reflect actual BHP enrollment during a year, within each applicable category, and prospectively determined federal payment rates for each category of BHP
enrollment, with such categories defined in terms of age range if applicable, geographic area, coverage status, household size, and income range, as explained above.
We are finalizing our proposal to require the use of certain rate cells as part of this final methodology. For each state, we will use rate cells that separate the BHP population into separate cells based on the five factors described as follows:
Factor 1Age: We will separate enrollees into rate cells by age if applicable, using the following age ranges that capture the widest variations in premiums under HHSs Default Age Curve: 5
5 This curve is used to implement the Patient Protection and Affordable Care Acts 3:1 limit on age-rating in states that do not create an alternative rate structure to comply with that limit. The curve applies to all individual market plans, both within and outside the Exchange. The age bands capture the principal allowed age-based variations in premiums as permitted by this curve. The default age curve was updated for plan or policy years beginning on or after January 1, 2018 to include different age rating factors between children 014
and for persons at each age between 15 and 20.
More information is available at https
www.cms.gov/CCIIO/Programs-and-Initiatives/
Health-Insurance-Market-Reforms/Downloads/
StateSpecAgeCrv053117.pdf. Both children and adults under age 21 are charged the same premium.
For adults age 2164, the age bands in this notice divide the total age-based premium variation into the three most equally-sized ranges defining size by the ratio between the highest and lowest premiums within the band that are consistent with the age-bands used for risk-adjustment purposes in the HHS-Developed Risk Adjustment Model. For such age bands, see HHS-Developed Risk Adjustment Model Algorithm Do It Yourself DIY Software Instructions for the 2018 Benefit
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Ages 020.
Ages 2134.
Ages 3544.
Ages 4554.
Ages 5564.
This provision is unchanged from the current methodology.6
Factor 2Geographic area: For each state, we will separate enrollees into rate cells by geographic areas within which a single RP is charged by QHPs offered through the states Exchange.
Multiple, non-contiguous geographic areas will be incorporated within a single cell, so long as those areas share a common RP.7 This provision is also unchanged from the current methodology.
Factor 3Coverage status: We will separate enrollees into rate cells by coverage status, reflecting whether an individual is enrolled in self-only coverage or persons are enrolled in family coverage through the BHP, as provided in section 1331d3Aii of the Patient Protection and Affordable Care Act. Among recipients of family coverage through the BHP, separate rate cells, as explained below, will apply based on whether such coverage involves two adults alone or whether it involves children. This provision is unchanged from the current methodology.
Factor 4Household size: We will continue the current methods for separating enrollees into rate cells by household size that states use to determine BHP enrollees household income as a percentage of the FPL under 600.320 Determination of eligibility for and enrollment in a standard health plan. We will require separate rate cells for several specific household sizes. For each additional member above the largest specified size, we will publish instructions for how we would develop additional rate cells and calculate an appropriate payment rate based on data for the rate cell with the closest specified household size. We will publish separate rate cells for household sizes of 1 through 10. This finalized Year, April 4, 2019 Update, https www.cms.gov/
CCIIO/Resources/Regulations-and-Guidance/
Downloads/Updated-CY2018-DIY-instructions.pdf.
6 In this document, references to the current methodology refer to the 2021 program year methodology as outlined in the 2021 final BHP
Payment Notice.
7 For example, a cell within a particular state might refer to County Group 1, County Group 2, etc., and a table for the state would list all the counties included in each such group. These geographic areas are consistent with the geographic areas established under the 2014 Market Reform Rules. They also reflect the service area requirements applicable to QHPs, as described in 45
CFR 155.1055, except that service areas smaller than counties are addressed as explained in this notice.

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provision is unchanged from the current methodology.
Factor 5Household Income: For households of each applicable size, we will continue the current methods for creating separate rate cells by income range, as a percentage of FPL. The PTC
that a person would receive if enrolled in a QHP through an Exchange varies by household income, both in level and as a ratio to the FPL. Thus, separate rate cells will be used to calculate federal BHP payment rates to reflect different bands of income measured as a percentage of FPL. We will use the following income ranges, measured as a percentage of the FPL:
0 to 50 percent of the FPL.
51 to 100 percent of the FPL.
101 to 138 percent of the FPL.8
139 to 150 percent of the FPL.
151 to 175 percent of the FPL.
176 to 200 percent of the FPL.
This provision is unchanged from the current methodology.
These rate cells will only be used to calculate the federal BHP payment amount. A state implementing a BHP
will not be required to use these rate cells or any of the factors in these rate cells as part of the state payment to the standard health plans participating in the BHP or to help define BHP
enrollees covered benefits, premium costs, or out-of-pocket cost-sharing levels.
Consistent with the current methodology, we are finalizing our proposal to use averages to define federal payment rates, both for income ranges and age ranges if applicable, rather than varying such rates to correspond to each individual BHP
enrollees age if applicable and income level. This approach will increase the administrative feasibility of making federal BHP payments and reduce the likelihood of inadvertently erroneous payments resulting from highly complex methodologies. This approach should not significantly change federal payment amounts, since within applicable ranges; the BHP-eligible population is distributed relatively evenly.
The number of factors contributing to rate cells, when combined, can result in over 350,000 rate cells, which can increase the complexity when generating quarterly payment amounts.
In future years, and in the interest of administrative simplification, we will consider whether to combine or eliminate certain rate cells, once we are certain that the effect on payment would be insignificant.
8 The three lowest income ranges will be limited to lawfully present immigrants who are ineligible for Medicaid because of immigration status.

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