CMS-10433 Appendix C 1 Rating Tables and Issuer Business Rules

Appendix C.1 QHP Rating Tables and Issuer Business Rules
Data Requirements
The following is a list of the specific rating table and issuer business rules data elements
to be collected for QHPs. Data will be pre-populated from HIOS or other templates
whenever possible.

Rating Table Data Elements
1. Issuer ID—Five-digit number that identifies the issuer.
2. Federal TIN—The Taxpayer Identification Number (TIN) used to identify a
business entity.
3. Rate Effective Date—Date when a rate goes into effect for a plan.
4. Rate Expiration Date—Date when a rate is no longer available for a plan.
5. Plan ID—14 digit number that identifies the Plan.
6. Rating Area ID—Identifies a specific geographic rating area as defined by a
State.
7. Age—The age of a subscriber eligible for the rate.
8. Tobacco Use—Tobacco use of subscriber used to determine if a person is
eligible for a rate from a plan.
9. Individual—Individual enrollee on a plan.
10. Primary Subscriber and Secondary Subscriber—A couple rate based on the
pairing of a primary enrollee and a secondary subscriber (e.g. husband and
spouse).
11. Primary Subscriber and One Dependent—A family rate for a single parent with
one dependent.
12. Primary Subscriber and Two Dependents—A family rate for a single parent with
two dependents.
13. Primary Subscriber and Three or More Dependents—A family rate for a single
parent with three or more dependents.
14. Primary Subscriber, Secondary Subscriber and One Dependent—A family rate
for a couple with one dependent.
15. Primary Subscriber, Secondary Subscriber and Two Dependents—A family rate
for a couple with two dependents.
16. Primary Subscriber, Secondary Subscriber and Three or More Dependents—A
family rate for a couple with three or more dependents.

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Issuer Business Rules Data Elements
1. Issuer ID—Five-digit number that identifies the issuer.
2. Federal TIN—The Taxpayer Identification Number (TIN) used to identify a
business entity.
3. Product Level Rules—10-character alphanumeric code that identifies a product.
4. Plan Level Rules—14-digit number that identifies the plan.
5. How are rates calculated for contracts covering two or more enrollees?—
Determines if a returned rate is the sum of individual rates or a group rate is
available.
6. What is the maximum number of dependents used to quote a two-parent family?
For a two-parent family, group rates are based on the number of dependents up
to the maximum amount stated.
7. What is the maximum number of dependents used to quote rates for a single
parent family? For a single-parent family, group rates are based on the number of
dependents up to the maximum amount stated.
8. Is there maximum age for a dependent?—When the business rules says to add
up individual rates, this determines the age range to be used to return rates for
dependents.
9. What is the maximum number of children used to quote rates for a children-only
contract?—Defines how many children rates are added up to determine the
overall rate, if more than one child is eligible for a child-only policy.
10. Are domestic partners treated the same as secondary subscribers?—Defines the
rules for treating a domestic partner when determining whether a couple is
eligible for a rate.
11. Are same-sex partners treated the same as secondary subscribers?—Defines
the rules for treating a same sex partner when determining whether a couple is
eligible for a rate.
12. How is age determined for rating and eligibility purposes?—Defines the rules for
determining the eligibility of subscribers based on their age in relation to rate
effective dates.
13. How is tobacco status determined for subscribers and dependents? —Defines
the rules for determining whether a subscriber or dependent are considered
tobacco users.
14. What relationships are allowed between the primary subscriber and dependent,
and is the dependent required to live in the same household as the primary
subscriber?—Defines the rules for allowable dependent relationships to the
primary subscriber, and determines whether that dependent is required to live in
the same household as the primary subscriber.

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