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 PY21:
  • New field added for “Medical, Dental, or Both?” Issuers indicate whether they are entering rating business rules for medical plans only, dental plans only, or both medical and dental plans.
  • New field added for “Medical or Dental Rule?” Issuers may enter different allowed values for template fields based on whether a rule is Medical or Dental.
  • New field added for “What is the maximum number of rated underage dependents on this policy?”
  • The following fields are removed from the template: TIN; How are rates for contracts covering two or more enrollees calculated?; What are the maximum number of under age (under 21) dependents used to quote a two parent family?; What are the maximum number of under age (under 21) dependents used to quote a single parent family?; What are the maximum number of children used to quote a children-only contract?; Are domestic partners treated the same as secondary subscribers?; and Are same-sex partners treated the same as secondary subscribers?
  • The following dependent relationship options are removed from the template: Father or Mother; Grandfather or Grandmother; Uncle or Aunt; Cousin; Adopted Child; Son-in-Law or Daughter-in-Law; Brother-in-Law or Sister-in-Law; Father-in-Law or Mother-in-Law; Stepparent; Dependent of a Minor Dependent; Guardian; Court Appointed Guardian; Annuitant; and Trustee.

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 fields, which are locked until “Medical, Dental, or Both?” is populated.
  • Rules associated with individual and SHOP plans should be entered into one Business Rules Template.
  • The first row of rules (Row 10) is the base set of issuer business rules, which must have blank values for the product ID and plan ID and must have data entered 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. Products or plans with rules that differ from the base set of issuer business rules are defined at the product or plan level in the subsequent rows.

Application Resources