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Federal Register / Vol. 86, No. 127 / Wednesday, July 7, 2021 / Rules and Regulations
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Information and Regulatory Affairs has determined this rulemaking is economically significant as measured by the $100 million threshold under Executive Order 12866, and hence also a major rule under the Congressional Review Act, 5 U.S.C. 8042.
Accordingly, we have prepared a RIA
that, to the best of our ability, presents the costs and benefits of the rulemaking.
C. Detailed Economic Analysis The aggregate economic impact of this payment methodology is estimated to be $1,114 million in transfers for CY 2022
measured in real 2022 dollars, which would be an increase in federal payments to the state BHPs. For the purposes of this analysis, we have assumed that two states would implement BHPs in 2022. This assumption is based on the fact that two states have established a BHP to date, and we do not have any indication that additional states may implement the program. We also assumed there would be approximately 926,000 BHP enrollees in 2022. The size of the BHP depends on several factors, including the number of and which particular states choose to implement or continue a BHP, the level of QHP premiums, and the other coverage options for persons who would be eligible for the BHP. In particular, while we generally expect that many enrollees would have otherwise been enrolled in a QHP on the Exchange, some persons may have been eligible for Medicaid under a waiver or a state health coverage program. For those who would have enrolled in a QHP and thus would have received PTCs, the federal expenditures for the BHP would be expected to be more than offset by a reduction in federal expenditures for PTCs. For those who would have been enrolled in Medicaid, there would likely be a smaller offset in federal expenditures to account for the federal share of Medicaid expenditures, and for those who would have been covered in non-federal programs or would have been uninsured, there likely would be an increase in federal expenditures.
Projected BHP enrollment and expenditures under the previous payment methodology were calculated using the most recent 2021 QHP
premiums and state estimates for BHP
enrollment. We projected enrollment for 2022 using the projected increase in the number of adults in the U.S. from 2021
to 2022 0.4 percent, and we projected premiums using the NHE projection of premiums for private health insurance 4.7 percent. Prior to any changes made in the 2022 BHP payment methodology, federal BHP expenditures are projected to be $6,738 million in 2022. This
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projection serves as our baseline scenario when estimating the net impact of the 2022 final methodology on federal BHP expenditures.
The change in the PTCF percentages is the most significant change in the methodology from the proposed notice, and is prescribed in the ARP. To calculate the changes that result from these changes in the payment methodology, we compared the results before and after these changes using the BHP payment model, we maintain to calculate payments to states, with projections used to calculate impacts in 2022. We recalculated the BHP
payments using the new PTCF
percentages to calculate the impact of this change, and we estimate that this would increase BHP payments by $853
million in 2022 as compared to using the previous PTCF percentages, as described in the proposed methodology. The new PTCF
percentages can be found in Table 1 in section III.D.5 of this final notice. For the change in the methodology to remove the MTSF for benefit year 2022, the MTSF was calculated as having a value of 96.68 percent as described previously. We recalculated the BHP
payments excluding the MTSF from the formula, and we estimate this would increase BHP payments by $261 million in 2022 as compared to the payments using a methodology including the MTSF factor. The projected BHP
expenditures after these changes are $7,852 million, which is the sum of the prior estimate $6,738 million and the impacts of the changes to the methodology $853 million and $261
million.

specific factors and conditions. For example, total federal BHP payment amounts may be greater in more populous states simply by virtue of the fact that they have a larger BHP-eligible population and total payment amounts are based on actual enrollment.
Alternatively, total federal BHP
payment amounts may be lower in states with a younger BHP-eligible population as the RP used to calculate the federal BHP payment will be lower relative to older BHP enrollees. While state composition will cause total federal BHP payment amounts to vary from state to state, we believe that the methodology, like the methodology used in 2021, accounts for these variations to ensure accurate BHP
payment transfers are made to each state.

D. Alternative Approaches We considered several alternatives in developing the BHP payment methodology for 2022, and we discuss some of these alternatives below.
We considered alternatives as to how to calculate the PAF in the final methodology for 2022. The value for the PAF is 1.188, which is the same as was used for 2018, 2019, 2020, and 2021. We believe it would be difficult to obtain the updated information from QHP
issuers comparable to what was used to develop the 2018 factor, because QHP
issuers may not distinctly consider the impact of the discontinuance of CSR
payments on the QHP premiums any longer. We do not have reason to believe that the value of the PAF would change significantly between program years 2018 and 2022. We are continuing to consider whether or not there are other methodologies or data sources we may TABLE 2ESTIMATED FEDERAL IMbe able to use to calculate the PAF.
PACTS FOR THE BASIC HEALTH PROWe also considered alternatives as GRAM 2022 PAYMENT METHODhow to calculate the MTSF in the final methodology for 2022. Given the OLOGY
changes made to the determination of Millions of 2022 dollars PTC for 2022 in the ARP, we are not including the MTSF in the 2022
Projected Federal BHP Payments under 2021 Final Methodology $6,738 payment methodology, as described in section III.D.6. of this final notice.
Projected Federal BHP Payment We also considered whether to under 2022 Final Methodology 7,852
Federal costs
1,114 continue to provide states the option to develop a protocol for a retrospective Totals may not add due to rounding.
adjustment to the PHF as we did in The provisions of this final previous payment methodologies. We methodology are designed to determine believe that continuing to provide this the amount of funds that will be option is appropriate and likely to transferred to states offering coverage improve the accuracy of the final through a BHP rather than to payments.
individuals eligible for federal financial We also considered whether to assistance for coverage purchased on the require the use of the program year Exchange. We are uncertain what the premiums to develop the federal BHP
total federal BHP payment amounts to payment rates, rather than allow the states will be as these amounts will vary choice between the program year from state to state due to the statepremiums and the prior year premiums
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