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Federal Register / Vol. 86, No. 127 / Wednesday, July 7, 2021 / Rules and Regulations determining the median adjustment.11
The median adjustment for silver level QHPs is the nationwide median adjustment.
For each of the two BHP states, we determined the median premium adjustment for all silver level QHPs in that state, which we refer to as the state median adjustment. The PAF for each BHP state equaled one plus the nationwide median adjustment divided by one plus the state median adjustment for the BHP state. In other words, PAF = 1 + Nationwide Median Adjustment 1 + State Median AdjustmentQ P=02
To determine the PAF described above, we sought to collect QHP
information from QHP issuers in each state and the District of Columbia to determine the premium adjustment those issuers made to each silver level plan offered through the Exchange in 2018 to account for the end of CSR
payments. Specifically, we sought information showing the percentage change that QHP issuers made to the premium for each of their silver level plans to cover benefit expenditures associated with the CSRs, given the lack of CSR payments in 2018. This percentage change was a portion of the overall premium increase from 2017 to 2018.
According to our records, there were 1,233 silver-level QHPs operating on Exchanges in 2018. Of these 1,233
QHPs, 318 QHPs 25.8 percent responded to our request for the percentage adjustment applied to silverlevel QHP premiums in 2018 to account for the discontinuance of the CSRs.
These 318 QHPs operated in 26 different states, with 10 of those states running SBEs while we requested information only from QHP issuers in states serviced by an FFE, many of those issuers also had QHPs in states operating SBEs and submitted information for those states as well. Thirteen of these 318 QHPs were in New York and none were in Minnesota. Excluding these 13 QHPs from the analysis, the nationwide median adjustment was 20.0 percent. Of the 13 QHPs in New York that responded, the state median adjustment was 1.0 percent. We believe that this is an appropriate adjustment for QHPs in Minnesota, as well, based on the observed changes in New Yorks QHP
premiums in response to the discontinuance of CSR payments and the operation of the BHP in that state 11 Some examples of outliers or unreasonable adjustments include but are not limited to values over 100 percent implying the premiums doubled or more because of the adjustment, values more than double the otherwise highest adjustment, or non-numerical entries.

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and our analysis of expected QHP
premium adjustments for states with BHPs. We calculated the final PAF as 1
+ 20% 1 + 1% or 1.20/1.01, which results in a value of 1.188.
We are finalizing our proposal to continue to set the PAF to 1.188 for program year 2022. We believe that this value for the PAF continues to reasonably account for the increase in silver-level premiums experienced in non-BHP states that took effect after the discontinuance of the CSR payments.
We believe that the impact of the increase in silver-level premiums in 2022 can reasonably be expected to be similar to that in 2018, because the discontinuation of CSR payments has not changed. Moreover, we believe that states and QHP issuers have not significantly changed the manner and degree to which they are increasing QHP silver-level premiums to account for the discontinuation of CSR payments since 2018, and we expect the same for 2022.
In addition, the percentage difference between the average second lowest-cost silver level QHP and the bronze-level QHP premiums has not changed significantly since 2018, and we do not expect a significant change for 2022. In 2018, the average second lowest-cost silver level QHP premium was 41.1
percent higher than the average lowestcost bronze-level QHP premium $481
and $341, respectively. In 2021, the latest year for which premiums have been published, the difference is similar; the average second lowest-cost silver-level QHP premium is 37.8
percent higher than the average lowestcost bronze-level QHP premium $452
and $328, respectively.12 In contrast, the average second lowest-cost silverlevel QHP premium was only 23.8
percent higher than the average lowestcost bronze-level QHP premium in 2017
$359 and $290, respectively.13 If there were a significant difference in the amounts that QHP issuers were increasing premiums for silver-level QHPs to account for the discontinuation of CSR payments over time, then we would expect the difference between the bronze-level and silver-level QHP
premiums to change significantly over time, and that this would be apparent in comparing the lowest-cost bronze-level 12 See Kaiser Family Foundation, Average Marketplace Premiums by Metal Tier, 20182021, https www.kff.org/health-reform/state-indicator/
average-marketplace-premiums-by-metal-tier/.
13 See Basic Health Program: Federal Funding Methodology for Program Years 2019 and 2020;
Final Methodology, 84 FR 59529 at 59532
November 5, 2019.

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QHP premium to the second lowest-cost silver-level QHP premium.
3. Population Health Factor PHF
We are finalizing our proposal to include the PHF in the methodology to account for the potential differences in the average health status between BHP
enrollees and persons enrolled through the Exchanges. To the extent that BHP
enrollees would have been enrolled through an Exchange in the absence of a BHP in a state, the exclusion of those BHP enrollees in the Exchange may affect the average health status of the overall population and the expected QHP premiums.
We currently do not believe that there is evidence that the BHP population would have better or poorer health status than the Exchange population. At this time, there continues to be a lack of data on the experience in the Exchanges that limits the ability to analyze the potential health differences between these groups of enrollees. More specifically, Exchanges have been in operation since 2014, and 2 states have operated BHPs since 2015, but data is not available to do the analysis necessary to determine if there are differences in the average health status between BHP and Exchange enrollees.
In addition, differences in population health may vary across states. We also do not believe that sufficient data would be available to permit us to make a prospective adjustment to the PHF
under 600.610c2 for the 2022
program year.
Given these analytic challenges and the limited data about Exchange coverage and the characteristics of BHPeligible consumers, the PHF will be 1.00
for program year 2022.
In previous years BHP payment methodologies, we included an option for states to include a retrospective population health status adjustment.
States will have same option for 2022 to include a retrospective population health status adjustment in the certified methodology, which is subject to our review and approval. This option is described further in section III.F. of this final methodology. Regardless of whether a state elects to include a retrospective population health status adjustment, we anticipate that, in future years, when additional data becomes available about Exchange coverage and the characteristics of BHP enrollees, we may propose a different PHF.
While the statute requires consideration of risk adjustment payments and reinsurance payments insofar as they would have affected the PTC that would have been provided to BHP-eligible individuals had they
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