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156.947

Federal Register / Vol. 86, No. 85 / Wednesday, May 5, 2021 / Rules and Regulations The record.

156.1210

Dispute submission.

a Responses to reports. Within 90
calendar days of the date of a payment and collections report from HHS, the issuer must, in a form and manner specified by HHS or the State Exchange describe to HHS or the State Exchange as applicable any inaccuracies it identifies in the report.
b Inaccuracies identified after 90day period. With respect to an inaccuracy described under paragraph a of this section that is identified and submitted to HHS or the State Exchange as applicable by the issuer after the end of the 90-day period described in such paragraph, HHS will consider and work with the issuer or the State Exchange as applicable to resolve the inaccuracy so long as 1 The issuer promptly notifies HHS
or the State Exchange as applicable upon identifying the inaccuracy, but in no case later than 15 calendar days after identifying the inaccuracy; and 2 The failure to identify the inaccuracy and submit it to HHS or the State Exchange as applicable in a timely manner was not unreasonable or due to the issuers misconduct or negligence.
c Deadline for describing inaccuracies. To be eligible for resolution under paragraph b of this section, an issuer must describe all inaccuracies identified in a payment and collections report before the later of 1 The end of the 3-year period beginning at the end of the plan year to which the inaccuracy relates; or 2 The date by which HHS notifies issuers that the HHS audit process with respect to the plan year to which such inaccuracy relates has been completed.
3 If a payment error is discovered after the timeframes set forth in paragraph c1 and 2 of this section, the issuer must notify HHS, the State Exchange, or SBEFP as applicable and repay any overpayments to HHS.

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22:49 May 04, 2021

48. Section 156.1215 is amended by revising paragraph b to read as follows:

Authority: 42 U.S.C. 300gg18.

a Any testimony that is taken inperson, by telephone, or by video teleconference is recorded and transcribed. The ALJ may order that other proceedings in a case, such as a prehearing conference or oral argument of a motion, be recorded and transcribed.

47. Section 156.1210 is amended by a. Revising paragraph a;
b. Redesignating paragraph b as paragraph d; and c. Adding new paragraphs b and c.
The additions read as follows:

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156.1215 Payment and collections processes.

b Netting of payments and charges for later years. As part of its payment and collections process, HHS may net payments owed to issuers and their affiliates operating under the same tax identification number against amounts due to the Federal government from the issuers and their affiliates under the same taxpayer identification number for advance payments of the premium tax credit, advance payments of and reconciliation of cost-sharing reductions, payment of Federallyfacilitated Exchange user fees, payment of State Exchanges utilizing the Federal platform user fees, and risk adjustment, reinsurance, and risk corridors payments and charges.

49. Section 156.1220 is amended by a. Revising paragraphs a1vii and a3ii;
b. Redesignating paragraphs a3iii through vi as a3iv through vii, respectively; and c. Adding new paragraph a3iii.
The revision and addition reads as follows:
156.1220

Administrative appeals.

a
1
vii The findings of a second validation audit as a result of risk adjustment data validation if applicable with respect to risk adjustment data for the 2016 benefit year and beyond; or

3
ii For a risk adjustment payment or charge, including an assessment of risk adjustment user fees, within 30 calendar days of the date of the notification under 153.310e of this subchapter;
iii For the findings of a second validation audit if applicable, or the calculation of a risk score error rate as a result of risk adjustment data validation, within 30 calendar days of publication of the applicable benefit years Summary Report of Benefit Year Risk Adjustment Data Validation Adjustments to Risk Adjustment Transfers;

PART 158ISSUER USE OF PREMIUM
REVENUE: REPORTING AND REBATE
REQUIREMENTS
50. The authority citation for part 158
continues to read as follows:

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51. Section 158.103 is amended by adding the definition for Prescription drug rebates and other price concessions in alphabetical order to read as follows:

158.103

Definitions.

Prescription drug rebates and other price concessions means all remuneration received by or on behalf of an issuer, including remuneration received by and on behalf of entities providing pharmacy benefit management services to the issuer, that decrease the costs of a prescription drug covered by the issuer, regardless from whom the remuneration is received for example, pharmaceutical manufacturer, wholesaler, retail pharmacy, or vendor.
Prescription drug rebates and other price concessions include discounts, charge backs or rebates, cash discounts, free goods contingent on a purchase agreement, up-front payments, coupons, goods in kind, free or reduced-price services, grants, or other price concessions or similar benefits to the extent the value of these items reduce costs for the issuer, and excluding bona fide service fees. Prescription drug rebates and other price concessions exclude any remuneration, coupons, or price concessions for which the full value is passed on to the enrollee. Bona fide service fees mean fees paid by a drug manufacturer to an entity providing pharmacy benefit management services to the issuer that represent fair market value for a bona fide, itemized service actually performed on behalf of the manufacturer that the manufacturer would otherwise perform or contract for in the absence of the service arrangement, and that are not passed on in whole or in part to a client or customer of an entity, whether or not the entity takes title to the drug.

158.221

Amended
52. Effective May 5, 2021 amend 158.221 by removing paragraph b8
and redesignating paragraph b9 as paragraph b8.
53. Section 158.240 is amended by adding paragraph g to read as follows:

158.240 Rebating premium if the applicable medical loss ratio standard is not met.

g Rebate prepayment and safe harbor. An issuer may choose to pay a portion or all of its estimated rebate amount for a given MLR reporting year to enrollees in any form specified in 158.241 prior to the rebate payment
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