Business Rules

All issuers must provide a series of questions and answers that define the business rules used to calculate rates and determine consumer eligibility for a plan. This information, in conjunction with a plan’s rates, are used in the calculations of the premiums for each enrollment group.

Key Changes for PY2024:
  • The template requires a data entry of Age on effective date for the field How is age determined for rating and eligibility purposes? for all Medical and Dental business rules. The template will auto-populate this value for the issuer-level business rule, and any product or plan-level rule. You will no longer be able to enter any of the following field values: Age on January 1 of the effective date year, Age on insurance date (age on birthday nearest the effective date), or Age on January 1 or July 1.

Tips for the Business Rules Section

  • Enter values for HIOS Issuer ID and Medical, Dental, or Both? before entering data for the rest of the template. All other fields are locked until you respond to Medical, Dental, or Both?
  • All rules associated with Individual Market and SHOP Market plans must be entered in a single Business Rules Template.
  • The first row of rules (row 10) is the base set of issuer business rules. Leave the product ID and plan ID fields blank in this row, but enter data for all subsequent columns. This row applies to all products and plans associated with the HIOS Issuer ID, including individual, SHOP, QHP, and SADP products and plans. Define how product or plan rules differ from the base set of issuer business rules in the subsequent rows, as applicable.