83_FR_56547 83 FR 56328 - Basic Health Program; Final Administrative Order

83 FR 56328 - Basic Health Program; Final Administrative Order

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

Federal Register Volume 83, Issue 219 (November 13, 2018)

Page Range56328-56347
FR Document2018-24673

This notice serves to announce that a Final Administrative Order related to the Basic Health Program (BHP) was issued to the States of New York and Minnesota on August 24, 2018.

Federal Register, Volume 83 Issue 219 (Tuesday, November 13, 2018) 
[Federal Register Volume 83, Number 219 (Tuesday, November 13, 2018)]
[Notices]
[Pages 56328-56347]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2018-24673]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-2416-N]


Basic Health Program; Final Administrative Order

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice of Final Administrative Order.

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SUMMARY: This notice serves to announce that a Final Administrative 
Order related to the Basic Health Program (BHP) was issued to the 
States of New York and Minnesota on August 24, 2018.

DATES: The Final Administrative Order was effective August 24, 2018.

FOR FURTHER INFORMATION CONTACT: Christopher Truffer, (410) 786-1264; 
Meg Barry, (410) 786-1536.

SUPPLEMENTARY INFORMATION:

I. Background and Provisions of the Notice

    The CMS Administrator issued a Final Administrative Order to set 
forth the revised payment methodology that applies to the Basic Health 
Program for 2018 only (HHS Revised BHP Payment Methodology). The 
Administrative Order is an agency action under 5 U.S.C. 551(13), issued 
pursuant to 5 U.S.C. 555(b) and (e).
    The HHS Revised BHP Payment Methodology modifies the existing 
methodology for 2018, which is set forth in the payment notice entitled 
``Basic Health Program; Federal Funding Methodology for Program Years 
2017 and 2018'' (81 FR 10091, February 29, 2016) (February 2016 Payment 
Notice). The modification involves the application of a Premium 
Adjustment Factor (PAF) that considers the premium increases in other 
states that became effective after the Centers for Medicare & Medicaid 
Services (CMS), an operating division of the U.S. Department of Health 
and Human Services (HHS), discontinued payments to issuers for cost-
sharing reductions (CSRs) provided to enrollees in qualified health 
plans (QHPs) offered on health insurance Exchanges.
    On July 6, 2018, pursuant to an amended stipulated order issued in 
State of New York v. U.S. Department of Health and Human Services, 18-
cv-00683 (S.D.N.Y. filed Jan. 26, 2018), CMS issued a Draft 
Administrative Order on which New York and Minnesota (the States) had 
an opportunity to comment. The States each submitted comments on August 
6, 2018. CMS considered those comments in issuing the Final 
Administrative Order, which adopts the HHS Revised BHP Payment 
Methodology for 2018 as set forth in the Draft Administrative Order.

II. Collection of Information Requirements

    This document does not impose information collection requirements, 
that is, reporting, recordkeeping, or third-party disclosure 
requirements. Consequently, review by the Office of Management and 
Budget under the authority of the Paperwork Reduction Act of 1995 (44 
U.S.C. 3501, et seq.) is not required.

III. Addendum

    We are publishing the Final Administrative Order as an addendum to 
this Notice.

    Dated: November 2, 2018.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
 BILLING CODE 4120-01-P

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[FR Doc. 2018-24673 Filed 11-9-18; 8:45 am]
 BILLING CODE 4120-01-C

56328 Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices screenings? If yes, please explain the submissions containing private or methodology for 2018, which is set forth scheduling issue that is a barrier and proprietary information such as Social in the payment notice entitled ‘‘Basic provide recommendations for how it Security numbers, medical information, Health Program; Federal Funding could be overcome. and/or inappropriate language. Methodology for Program Years 2017 6. Does concern about the Comments may be submitted on any and 2018’’ (81 FR 10091, February 29, confidentiality of medical information topic related to this action. All public 2016) (February 2016 Payment Notice). pose a barrier to participation? If this is comments will be posted in the docket The modification involves the a barrier, then please provide for this action at https:// application of a Premium Adjustment recommendations or suggestions for www.regulations.gov. Factor (PAF) that considers the how it can be overcome. premium increases in other states that John J. Howard, 7. Does concern that the early became effective after the Centers for identification of dust-related lung Director, National Institute for Occupational Medicare & Medicaid Services (CMS), Safety and Health, Centers for Disease Control disease might adversely affect a miner’s and Prevention. an operating division of the U.S. career (e.g., prevent career advancement Department of Health and Human [FR Doc. 2018–24700 Filed 11–9–18; 8:45 am] or the ability to get a new coal mining Services (HHS), discontinued payments BILLING CODE 4163–19–P job) pose a barrier to participation? If to issuers for cost-sharing reductions this is a barrier, then please provide (CSRs) provided to enrollees in recommendations or suggestions for qualified health plans (QHPs) offered on DEPARTMENT OF HEALTH AND how it can be overcome. health insurance Exchanges. HUMAN SERVICES 8. Does concern that early On July 6, 2018, pursuant to an identification of dust-related lung Centers for Medicare & Medicaid amended stipulated order issued in disease might affect subsequent Services State of New York v. U.S. Department of eligibility for compensation through Health and Human Services, 18–cv– Federal or State programs pose a barrier [CMS–2416–N] 00683 (S.D.N.Y. filed Jan. 26, 2018), to participation? If this is a barrier, then CMS issued a Draft Administrative Basic Health Program; Final please describe the specific Order on which New York and Administrative Order compensation programs and how Minnesota (the States) had an eligibility for them can be affected by AGENCY: Centers for Medicare & opportunity to comment. The States early detection of dust-related lung Medicaid Services (CMS), HHS. each submitted comments on August 6, disease. Please also provide ACTION: Notice of Final Administrative 2018. CMS considered those comments recommendations or suggestions for Order. in issuing the Final Administrative how this barrier could be overcome. Order, which adopts the HHS Revised 9. Does concern that personal finances SUMMARY: This notice serves to BHP Payment Methodology for 2018 as will require a miner to continue announce that a Final Administrative set forth in the Draft Administrative working despite early identification of Order related to the Basic Health Order. dust-related lung disease pose a barrier Program (BHP) was issued to the States to participation? If this is a barrier, of New York and Minnesota on August II. Collection of Information please provide recommendations or 24, 2018. Requirements suggestions for how it can be overcome. DATES: The Final Administrative Order This document does not impose 10. Are there any other barriers to was effective August 24, 2018. information collection requirements, participation that NIOSH should be FOR FURTHER INFORMATION CONTACT: that is, reporting, recordkeeping, or aware of? Christopher Truffer, (410) 786–1264; third-party disclosure requirements. Interested parties may participate in Meg Barry, (410) 786–1536. Consequently, review by the Office of this activity by submitting written SUPPLEMENTARY INFORMATION: Management and Budget under the views, opinions, recommendations, and authority of the Paperwork Reduction data. Comments received, including I. Background and Provisions of the Notice Act of 1995 (44 U.S.C. 3501, et seq.) is attachments and other supporting not required. materials, are part of the public record The CMS Administrator issued a and subject to public disclosure. Do not Final Administrative Order to set forth III. Addendum include any information in your the revised payment methodology that We are publishing the Final comment or supporting materials that applies to the Basic Health Program for Administrative Order as an addendum you do not wish to be disclosed. 2018 only (HHS Revised BHP Payment to this Notice. Although your name, contact Methodology). The Administrative information, or other information that Order is an agency action under 5 U.S.C. Dated: November 2, 2018. identifies you in the body of your 551(13), issued pursuant to 5 U.S.C. Seema Verma, comments will be on public display, 555(b) and (e). Administrator, Centers for Medicare & NIOSH will review all submissions and The HHS Revised BHP Payment Medicaid Services. may choose to redact or withhold Methodology modifies the existing BILLING CODE 4120–01–P amozie on DSK3GDR082PROD with NOTICES1 VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00055 Fmt 4703 Sfmt 4703 E:\FR\FM\13NON1.SGM 13NON1

Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices 56329 ADDENDUM HHS "'"'v'"'"" which set and the HHS forth Ad:mir:istrathre Order. amozie on DSK3GDR082PROD with NOTICES1 EN13NO18.099</GPH> VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00056 Fmt 4703 Sfmt 4725 E:\FR\FM\13NON1.SGM 13NON1

56330 Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices The result I. is standard health to enroll m state's make determine value amozie on DSK3GDR082PROD with NOTICES1 EN13NO18.100</GPH> VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00057 Fmt 4703 Sfmt 4725 E:\FR\FM\13NON1.SGM 13NON1

Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices 56331 other States with to nr•?vi.llen to residents other BHP BHP amozie on DSK3GDR082PROD with NOTICES1 EN13NO18.101</GPH> VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00058 Fmt 4703 Sfmt 4725 E:\FR\FM\13NON1.SGM 13NON1

56332 Federal Register/Vol. 83, No. 219 /Tuesday, November 13, 2018 /Notices CMCS Informational Bulletin, Rasic Health Program; Federal Funding Methodclogy for Program Year 2018 (May 17, 2017). In October 2017, in response to an inquiry from HHS and the Treasury Department, the Attorney Cieneral concluded "that the best interpretation of the law is that the permanent appropriation for ‘refunding intemal revenue collections," 31 U.S.C. §$1324, cannot be used to fund the CSR payments to insurers authorized by 42 U.S.C. $ 18071."° Letter from Attorney Gen. Jefferson R. Sessions [to Sec‘y of Treasury Steven Mnuchin & Acting Sec‘y of HHS Don Wright at 1 (Oct. 11, 2017). The next day, HHS sent a memorandum to CMS explaining that "CSR payments are prohibited unless and until a valid appropriation exists." Memoranduwm from Acting Sec‘y of HHS Eric Hargan to Adm‘r of CMS Seema Verma, Payments to Issuers for Cost—Sharing Reductions (CSRs), at 1 (Oct. 12, 2017}." Because to date no CSR appropriation has been enacted, CMS is prohibited from making further payments of the CSR component of any BHP payment. EL Frocedural Background Starting with the payment for the first quarter (Q1) of 2018 (which began on January 1, 2018}, CMS stopped paying the CSR component of the quarterly BHP payments to New York and Minnesota. The States then sued the Secretary for dectaratory and injfunctive relief in the United States District Court for the Southern District of New York. See State ofNew York, et al, v. U.S. Department ofHealth and Human Services, 18—cv—00683 (S.D.N.Y. filed Jan. 26, 3018HHS understands the States® complaint to seek to compel HHS to either pay the CSR component of their 2018 BHP payments as calculated under the methodology set forth in the February 2016 Payment ‘ The Attorney General‘s letter and the subsequent memmorandur from the Acting HHS Secretary are available at hittps//woywhhs. govisites/default/files/csr—payment—memo. pdf.

Federal Register/Vol. 83, No. 219 /Tuesday, November 13, 2018 /Notices 56333 Notice, or take other actions that would ostensibly yield BHP payments for 2018 that are greater than what CMS has paid. On May 2, 2018, the parties filed a stipulation requesting a 60—day stay of the litigation so that HHS may issue an administrative order revising the 2018 BHP payment methodology. As a result of the stipulation, the court dismissed the BHP litigation, althoughit retained jurisdiction to enforce the stipulation and re—open the docket. On June 8, 2018, the parties revised their stipuiation to amend the dates by which HHS would issue an administrative order. IIl. The HHS Revised BHMP Payment Methodology for 2018 The HHS Revised BHP Payment Methodology, which applies only for 2018, modifies the existing methodology for 2018 set forth in the February 2016 Payment Notice. The modification involves the application of a premium adjustment factor (PAF) to calculate the PTC portion of the BHP payment rates. Consistent with the February 2016 Payment Notice and prior years, the HHS Revised BHP Payment Methodology for 2018 determines the States‘ BHP payments based on muiltiple rate cells" applied to estimated BHP enrollment. CMS calculates the BHP payment rate for each rate cell in two parts. The first part equals 95 percent of the estimated PTC that would have been paid if a BHP enrollee in that rate cell had instead enrolled in a QHP through the State‘s Exchange. The second part equals 95 percent ofthe estimated CSR payment that would have been made if a BHP enrollee in that rate cell had instead enrolled in a QHP through the State‘s Exchange. * Each rate cell represents a unique combination of age range, geographic area, coverage category (for example, self only or two—adult coverage through BHP), household size, and income range as a percentage of FPL,. There is a distinet rate cell for individuals in each coverage category within a particular age range who reside in a specific geographic area and are in households ofthe same size and income range. In addition, the HHS Revised BHP Payment Methodology aligns with a state‘s rules on age rating. Thus, in the case of a state that does not use age as a rating factor on the Exchange, the BHP payment rates will not vary by age.

56334 Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices IRF • • • • • • • • • • • the BHP amozie on DSK3GDR082PROD with NOTICES1 EN13NO18.104</GPH> VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00061 Fmt 4703 Sfmt 4725 E:\FR\FM\13NON1.SGM 13NON1

Federal Register/Vol. 83, No. 219 /Tuesday, November 13, 2018 /Notices 56335 the payment formula based on consideration of the experience of other states regarding enrollee participation in metal tiers. The total BHP payment rate for each rate cell equals the sum of the PTC and CSR parts. CMS multiplies the rate for each rate cell by the number of BHP enrollees in that cell—that is, the number of enrollees that meet the criteria for each rate cell (£,4,4..)—to calculate the total monthly BHP payment to the state (PMT). The equation for this calculation is: PMT = Z{(wcmm + CSRageni) * EageRil In this equation, CMS assigns a value ofzero to the CSR part of the BHP payment rate calculation (CSRaq,4i) because there is presently no available appropriation from which CMS can make the CSR portion of any BHP paymflnt.3 Determination of the PAF The PAF considers the premium increases in other states that took effect after CMS discontinued payments to issuers for CSRs provided to enrollees in QHPs offered on state insurance Exchanges. The PAF is authorized by ACA § 1331(d)(3)(A)(ii), which says that the determination of the BHP payment amount "shall take into consideration the experience of other States with respect to participation in an Exchange and such [PTCs) and [CSRs]) provided to residents of the other States." CMS has calculated the PAF for each BHP state for 2018 as follows: a CMS sought to collect QHP issuer information from QHP issuers in each state and the District of Columbia, and then determine the premium adjustment that the responding QHP * in the event that an appropriation for CSRs for 2018 is made, CMS would reconsider whether to zero—out the CSR part of the BHP payment rate calculation (CSR,4,4;) and to include the FPAF in the HHS Revised BHP Methodology.

56336 Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices • • • PAF • 1.188. • 1.188. amozie on DSK3GDR082PROD with NOTICES1 EN13NO18.106</GPH> VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00063 Fmt 4703 Sfmt 4725 E:\FR\FM\13NON1.SGM 13NON1

u& — y In general, CMS has determined these specific true—up payments by calculating the total BHP payments for the first, second, and third quarters of 2018 under the HHS Revised BHP Methodology set forth in this Final Order and subtracting the amounts of the payments already made for those quarters {including the Q2 supplemental payments made to the states on or about May 14, 2018). If a state already received a total quarterly BHP payment exceeding the quarterly payment that CMS calculated under the HHS Revised BHP Methodology set forth in this Final Order, then CMS will offset the overpayment against the next quarterly payment to the state. CMS will make any future reconciliation payments (%e., those payments calculated retrospectively and based on final BHP enroliment for 2018, as compared to the quarterly payments based on estimated enrollment) using the HHS Revised BHP Methodology set forth in this Final Order, and otherwise consistent with the February 2016 Payment Notice. I¥. Facts and Data To determine the PAF described above, CMS requested information from QHP issuers in each state serviced by a Federally—facilitated Exchange (FFE) 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, CMS requested 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 CMS records, there are 1,233 silver—level QHPs operating on Exchanges in 2018,. COf these 1,233 QHPs, 318 QHPs {(25.8 percent) responded to CMS‘s request for the percentage adjustment applied to silver—level QHP premiums in 2018 to account for the discontinuance of the CSRs. These 318 QHPs operated in 26 different states with 10 of those

56338 Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices v. 10 amozie on DSK3GDR082PROD with NOTICES1 EN13NO18.108</GPH> VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00065 Fmt 4703 Sfmt 4725 E:\FR\FM\13NON1.SGM 13NON1

u& — y Exchange and such [PTCs]| and [CSRs] provided to residents of the other States," as required by ACA § 1331(d)(3X¥A)i1y. New York‘s enumerated comments submitted on August 6, 2018 and CMS‘ responses follow: 1. The methodology fails to detail how HHS accounts for the experiences of other states in estimating the median adjustment for silver—level QHPs nationwide. Specifically, the methodology does not set forth how CMS accounted for relative distributions of income, differences in rating rules, actual claims experiences, and differential approaches to adjust for the loss of CSRs. Response: The methodotogy described in the Draft Order adequately accounts for the experience ofother states with regard to the discontinuance of the CSR payments to QHPs. By surveying QHPs, we have taken into account the experience of states in the aggregate. Accounting for the impact of the discontinuance in each state at the level of detail New York suggests would be impractical, if not impossible, given (i) the multitude of state— specific factors noted above and (ii) the lack of clarity and transparency in how individual QHP issuers took these factors into account in making any adjustments to the QHP premiums. On page 7 of the Draft Administrative Order, CMS outlines how it will determine the PAF and claims that it will "collect QHP fssuer information from QHP issuers in each state and the District of Columbia"®" to account for the discontinuation of CSR payments to QHP issuers. However, page 9 of the Draft Administrative Order indicates that CMS only requested information from QHP issuers in states serviced by Federally—facilitated Exchanges ("FFEs"). As CMS itself seems to recognize, it cannot exclude states with State—based Exchanges ("SBEs") — particularly since the BHMPs are only in states with SBEs, CMS must provide clarity on whether it only reached out to QHP issuers in FFEs — and if so, provide an explanation as to why it did so and how that impacts its ability to accurately establish a nationwide median., Response: We disagree that surveying QHP issuers participating in SBEs is required to accurately establish a nationwide median, as we do not belifeve that QHP issuers in SBEs responded to the discontinuation of CSR payments differently than QHP issuers in FFEs. That is, we do not believe that the mere type of entity managing the Exchange, standing alone, affected QHP issuer behavior. Based on our survey of QHP issuers, we found that the mean premium adjustments by state ranged from 3.9 percent to 29.6 percent in states operating SBEs or SPEs in 2018 {9 states, excluding New York) and the median of these was 15.0 percent. The mean premium adjustments by state for states with FFEs in 2018 (15 states) were 9.25 percent to 32.5 percent, and the median of these was 19.9 percent. We believe that these mean premium rate increase ranges and medians are reasonably similar between the SBE/SPE states and FFE states, and that there is no apparent bias between the results. We also note to the 11

u& — y extent there is any difference between the premium rate increases and medians found in SBE/SPE states and FFE states, the rate increases were lower in SBE/SPE states. CMS was able to compile this rate increase data because CMS requested information from all OHP issuers participating in FFEs and SPEs. Becausemany ofthese issuers also offered OHPs in SBEs, they also reported adjustments for those QHPsto CMS.. Thus, while CMS did not directly solicit information from issuers that only offered QHPs on SBEs, CMS did receive adjustment information for QHPs offered on SBEs. Therefore, we do not believe that this approach impacted our ability to accurately establish a nattonwide median. The Draft Order states that the PAF is derived only from a very small pool of siltver—level OHPs (25.8%) and does not provide information regarding how many different states that represents. Relying on a small fraction of issuers‘ rate adjustments from an unspecified number of states does not appear to be sufficient to calculate & "nationwide median adjustment" as provided for in the Proposed Methodology. CMS should provide additional information on the issuers whose information was considered and why that survey is adequate to establish a natonwide median, Response: We disagree that the PAF is derived from a "very small pool" ofsilver—level (HPs. On the contrary, QHP issuers representing 26 differert states responded to our request for information, including 10 states that operated SBEs/SPEs in 2018. We do not believe, and have no reason to believe, there is any difference in the premium adjustments made hy QHP issuers that did report and those that did not report, The QHPs (and the states) represented in the sample—are reasonably representative of the nattionwide—results. Fundamentally, QHPs faced similar costs in cach state‘s Exchange, because the underlying actuarial values of the silver—level plans and the CSRs were the same. While there may be some underlying variations state—to—state (for example, the relative number of people receiving CSRs compared to those not receiving CSRs) and some states may have provided diffferent Instructions to QHPs, we received a range of results that adequately captured the experience across the states and various QHPs: Also, the results of the survey based on the responses that we received were generally consistent with public domain information regarding GHP issuers‘ adjustments to premiums to account for the discontinuance of CSR payments. For example, the Kaiser Family Foundation surveyed QHP issuers in October 2017 and found that siIver—level QHP premiums were adjusted between 0 and 38 percent for 2018 due to the discontinuance of the CSR payments, with a median adjustment of about 15 percent, (See Kaiser Family Foundation, "How the Loss of CostSharing Subsidy Payments is Affecting 2018 Premiums," October 2017; hitp/es kLorg/attachment‘Issue—Bref—How—the—Loss—of— CostSharing—Subsidy—Payments—ts—Affecting—2018—Premiums). In short, the response rate was sufficient to develop the nationwide median adjustment for use in the payment methodology.

u& — y 4. In describing the PAF, CMS states that "outlier" QHPs were not included in the factor. However, the Draft Order does not define "outlter" or provide any guidance as to when an adjustment would be excluded on such grounds. "Outlier" should be defined. Response: CMS considered outliers to be adjustments that were (1) negative or (2) excessively high (for example, above 100 percent). Of the responses CMS received, we considered only 1 an outlier (reporting a 2,000 percent increase), and we suspect this was a typographical error in reporting. CMS states that QHP issuers that made no CSR adjustment will count as "0" in determining the median adjustment made to all silver—level QHPs nationwide. New York disagrees with this determination because including these QHP issuers in the adjustment is contrary to the purpose of the BHP payment methodology. Only issuers that adjusted premiums in response to the CSR defunding should be included in the calculation of the PAF factor, as this is the relevant comparison group when adjusting for the experience of other states. By including issuers with no CSR adjustments, HHS is not calculating the PTC subsidy amount that "would have been provided" to BHP—eligible individuals in New York if they had enrolied in QHPs, as required by statute, See 42 U.S.C. § 18051(d)(3)(A)(iy; 42 C.FR. §600.605(a)(1 }—(2). Response: CMS, in accordance with ACA § 1331, sought to account for all states‘ experience in developing the PAF adjustment. No QHP issuers reported an adjustment of 0 for stiver—evel QHPs on Exchanges, and therefore no 0 adjustments were included in the calculation. That said, some states allowed or required (HP issuers to make no adjustment to 23018 premium amounts to account for the discontinuation of CSR payments, So we believe that "0%" adjustments would be acceptable because they reflect the experience of issuers in other states. Again, though, CMS made no such adjpestments, The Proposed Methodology does not address issuance ofquarterly payment letters to states. Payment letters providing the states with details on how the payment methodology is applied to the state‘s estimated enrollment submission for the following quarter should resume in August 2018 for quarter 4. Response: CMS intends to provide quarterty payment letters to the States, as it has done in the past, for future quarters starting with €24 of 2018. Comments from Minnesota with Responses from CMS ._ In section TV of the draft order, under the heading "Facts and Data," CMS explains that it requested information from issuers in each state serviced by a federally—facilitated marketplace. From the 25.8% of those issuers that responded, CMS calculated a median nationwide adjustment of 20 percent. It appears that CMS did not attempt to obtain data from issuers in state—based marketplaces and in state—partnership marketplaces. The draft order does not explain whether and how CMS plans to obtain data from issuers in these states to include in the calculation of the nationwide median adjustment. We recommend 13

that CMS survey all issuers, especially those in state—hbased marketplaces, before finalizing the value ofthe premium adjustment factor. As is, the lack ofrepresentation from the plans in state—based and partnership marketplaces that are more representative of Minnesota‘s individual insurance market is likely masking the nattionwide expenience. Response: We disagree that surveying QHP issuers participating in SBFs or SPF3s is retuired to accurately establish a nattonwide median, as we do not belteve that QHP issuers in SBEs or SPEs responded to the discontinuation of CSR payinents differently than QHP issuers in FFEs. That is, we do noot believe that the mere type of entity managing the Exchange, standing alone, affected (OHF issuer behavior: Based on our survey of QHP issuers, we found that the mean premfur adjustments by state faniged from 3.9 percent to 19.6 pervent in #tates operating SBEs or SPE# in 2018 (9 states, excluding New York) and the median of these was 15.0 percent. The mean premiom adjustments by—state for states with FFEs in 2018 (15 states) wore 9.25 pergent to 37.5 percent, and the median ofthese was 19.9 percent, We believe that these mean premium rate increase fanges and medians are reasongbly similar between the SBE/SPE states and FFE states, and that there is no apparent bigs between the results,. We also note to the extent there is any difference between the premlum rate increases and medians found in SRE/SPE states and FFE atates, the rate increases were lower in SRE/SPE states. CMS was able to compile this rate increase data becauseCMS requested information from all QHP issuers participating in FFEs and SPEs. Becausemany ofthese issuers also offered QHPs in SBEs, they also reported adjustments for thosw OHPs to CMS. Thus, whileCMS did not directly solicit information from issuers that only offered QHPs on SBEs, CMS did recéive adjustment information for QHPs offered on SBEs. We do aot believe that this approach impacted our ability to accurately establish a nationwide median. QHP issuers representing 26 different states responided to our request for information, including 10 states that operated SREs or SPEs in 2018. We do not believe, and have no reason to believe, there is any difference in the premium adjustments made by OHP issuers that did report and those that cid not report. Also, the—results of the survey based on the responses that we received were generally consistent with public domain information regarding QHP lsswers‘ adjuostments to premtums to account for the discontinuance of CSR payments. Forexample, the Kgiser Farmly Foundation surveyed QHP issuers in October 2017 and found that sitver—level QHF preminums were adjusted between 0 and 38 percent for 2018 due to the discontinuance of the CSR payments, with a median adjustment of about 15 percent. (See Kaiser Family Foundation, "How the Loss of CostSharing. Subsidy Payments is Affecting 2018 Premiums," October 2017 http/fleskfforpattachment{ssue—Bnef—How—the—Loss—of> ~Prempums). In short, the response rate was sufficient to develop the nationwide median adjustment for use in the payment methodology.

u& — y 2. Further, it is especially important that the factor determined for 2018 is based on data from a population including all the sitver—level issuers nationwide, and that the 1.188 forms the base for the future adjustments because QHP issuers will not be able to continue calculating the difference in premiums before and after the CSR loss after the 2018 coverage year. If it is not CMS" intent to obtain data from all issuers or from a more representative sample of issuers, then we suggest that the final methodology should itemize the exclusions and justify the resulting adjustment factor as a reasonable approximation of the experience in other states, including those not sampled., Response: The QHPs ({and the states) represented in the sample are reasomably representative ofthe nationwide results, Fundamentally, QHPs faced similar costs in each state exchange, because the underlying actuarial values of the silver—level plans and the CSRs were the same. While there may be some underlying variations state—to—state (for example, the relative number of people receiving CSRs compared to those not receiving CSRs) and some states may have provided different instructions to QHMPs, we received a range of results that adequately captured the experience across the states and various QHPs. CMS has not committed to a methodology for 2019 or beyond at this point in time. 3. On page 7 of the draft order, CMS notes that issuers that reported a zero increase were counted in the calculation of the median, but that CMS reserves the right to exclude reported amounts that are negative, outliers, or unreasonable. Including zero increases is inconsistent with the purpose of this adjustment factor, given that a zero increase is likely the result of decisions some states made to the detriment of policyholders. Also, for those amounts that were determined to be "outliers" or "unreasonable," CMS should itemize and explain those amounts that were excluded. Response: CMS, in accordance with ACA $ 1331, sought to account for all states‘ experience in developing the PAF adjustment. No QHP issuers reported an adjustment of 0 for silver—level QHPs on Exchanges, and therefore no 0 adjustments were included in the calculation. That said, some states allowed or required QHP issuers to make no adjustment to 2018 premium amounts to account for the discontinuation of CSR payments, So we believe that "0%" adjustments would be acceptable because they reflect the experience of issuers in other states. Again, though, no such adjustments were made, CMS considered outlhiers to be adjustments that were (1) negative or (2) excessively high {(for example, above 100 percent}. Of the responses CMS received, we considered only 1 an outlier (reporting a 2,000 percent increase), and we suspect this was a typographical error in reporting. 4. Finally, we urge CMS to finalize the payment methodology for 2019 as soon as possible. Response: CMS concurs, and CMS is at work on the 2019 and 2020 BHP payment methodologies. 15

u& — y Y¥L. BHP Payments for Q1—Q3 2018 Under The HHS Revised Payment Mcthodology Using the HHS Revised BHP Payment Methodology with PAF values of 1.188 for both New York and Minnesota as finalized in this Administrative Order and with enrollment data previously provided by the States, CMS calculates the States" BHP payments for the first three quarters of 2018 as listed in the tables below. These tables include the quarterly BHP payments CMS has made for Q1—Q3 2018 to New York and Minnesota, payment amounts for the same periods calculated under the HHS Revised Payment Methodology, 2 supplemental payments paid to the States in May 2018, and the resulting true—up payments CMS will make to the States by September 7, 2018. {Intentionally Left Blank]

Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices 56345 Difference amozie on DSK3GDR082PROD with NOTICES1 EN13NO18.115</GPH> VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00072 Fmt 4703 Sfmt 4725 E:\FR\FM\13NON1.SGM 13NON1

payment rates to the States. Wa are finalizing these reviged payment amounts for the first three quarters of 3018 in this Final Administrative Order. in addifion, CMS will use the finalized monthly BHP payment rates determined under the HHS Revised BHP Payment Methodology finalized in this Admimistrative OQrder to develop the States‘ reconciled BHP payments (using actual enrollment date the States submit after the close of the benefit yearr. ififiifimsfl.fih day of Ajigust, 2018. a d \ ppma) |prw—_ . ; . 1 j Seema Wmfia Admt ator Centers for Medicare &Medicaid Services U.S. De L;%sr%rzwt‘fi of Health and Human Services yous Bs

Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Notices 56347 [FR Doc. 2018–24673 Filed 11–9–18; 8:45 am] ACTION: Notice. Reduction Act of 1995 (44 U.S.C. 3507). BILLING CODE 4120–01–C The OMB control number and SUMMARY: The Food and Drug expiration date of OMB approval for Administration (FDA) is publishing a each information collection are shown DEPARTMENT OF HEALTH AND list of information collections that have been approved by the Office of in table 1. Copies of the supporting HUMAN SERVICES statements for the information Management and Budget (OMB) under Food and Drug Administration the Paperwork Reduction Act of 1995. collections are available on the internet FOR FURTHER INFORMATION CONTACT: Ila at http://www.reginfo.gov/public/do/ [Docket Nos. FDA–2017–N–0558; FDA– PRAMain. An Agency may not conduct 2017–N–1315; FDA–2011–N–0776; FDA– S. 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Activities; Announcement of Office of SUPPLEMENTARY INFORMATION: The Management and Budget Approvals following is a list of FDA information AGENCY: Food and Drug Administration, collections recently approved by OMB HHS. under section 3507 of the Paperwork TABLE 1—LIST OF INFORMATION COLLECTIONS APPROVED BY OMB OMB control Date approval Title of collection No. expires Disclosures in Professional and Consumer Prescription Drug Promotion .............................................................. 0910–0860 9/30/2020 Experimental Study of Risk Information Amount and Location in Direct-to-Consumer Print Ads .......................... 0910–0861 9/30/2020 Reclassification Petitions for Medical Devices ........................................................................................................ 0910–0138 9/30/2021 Request for Samples and Protocols ........................................................................................................................ 0910–0206 9/30/2021 Medical Device Recall Authority .............................................................................................................................. 0910–0432 9/30/2021 Food Safety, Health, and Diet Survey ..................................................................................................................... 0910–0345 10/31/2020 Medical Device Labeling Regulations ..................................................................................................................... 0910–0485 10/30/2021 GFI: Clinical Trial Sponsors on the Establishment and Operation of Clinical Trial Data Monitoring Committees 0910–0581 10/31/2021 Current Good Manufacturing Practice and Hazard Analysis and Risk-Based Preventive Controls for Human Food ..................................................................................................................................................................... 0910–0751 10/31/2021 Current Good Manufacturing Practice and Hazard Analysis and Risk-Based Preventive Controls for Food for Animals ................................................................................................................................................................. 0910–0789 10/31/2021 Dated: November 5, 2018. Prescription Drug User Fee Act (PDUFA information, please refer to https:// Leslie Kux, VI) and the 21st Century Cures Act www.fda.gov/AboutFDA/ Associate Commissioner for Policy. (Cures Act) by soliciting comments on WorkingatFDA/BuildingsandFacilities/ [FR Doc. 2018–24609 Filed 11–9–18; 8:45 am] Drug Development Tool Qualification at WhiteOakCampusInformation/ucm241 BILLING CODE 4164–01–P FDA related to the qualification process 740.htm. under section 507 of the Federal Food, You may submit comments as Drug, and Cosmetic Act (FD&C Act); follows. Please note that late, untimely DEPARTMENT OF HEALTH AND discussing taxonomy for biomarkers and filed comments may not be considered. HUMAN SERVICES related concepts used in drug For timely consideration we request that development; and planning activities to electronic comments be submitted on or Food and Drug Administration define a framework with appropriate before January 31, 2019. The https:// standards and scientific approaches to www.regulations.gov electronic filing [Docket No. FDA–2018–N–4100] support qualification for a specified system will accept comments until Drug Development Tool Process Under context of use. 11:59 p.m. Eastern Time on January 31, the 21st Century Cures Act and 2019. Comments received by mail/hand DATES: The public meeting will be held Prescription Drug User Fee Act VI; delivery/courier (for written/paper on December 11, 2018, from 9 a.m. to 5 Public Meeting; Request for Comments submissions) will be considered timely p.m. Submit either electronic or written if they are postmarked or the delivery comments on this public meeting by AGENCY: Food and Drug Administration, service acceptance receipt is on or January 31, 2019. See the HHS. before that date. SUPPLEMENTARY INFORMATION section for ACTION: Notice of public meeting; registration date and information. Electronic Submissions request for comments. 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Because your VerDate Sep<11>2014 17:34 Nov 09, 2018 Jkt 247001 PO 00000 Frm 00074 Fmt 4703 Sfmt 4703 E:\FR\FM\13NON1.SGM 13NON1


Document Created: 2018-11-10 03:18:25
Document Modified: 2018-11-10 03:18:25
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionNotices
ActionNotice of Final Administrative Order.
DatesThe Final Administrative Order was effective August 24, 2018.
ContactChristopher Truffer, (410) 786-1264; Meg Barry, (410) 786-1536.
FR Citation83 FR 56328 
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