Business Rules FAQs

Q1: In what circumstance would tobacco rates not display to a smoker?
  • Tobacco rates will not display to consumers if the issuer has not submitted tobacco rates. For issuers who submit tobacco rates, the tobacco rates will only apply to consumers who report their last smoking date more recently than the look-back period indicated in the issuer’s Business Rules Template. Issuers are not permitted to set the tobacco look-back period to a duration more than six months. In addition, a Qualified Health Plan (QHP) may not apply tobacco rating to the underage tobacco age bands of 0 through 20. For these age bands, a QHP cannot report a tobacco rate in the Rates Table Template that is different from the non-tobacco rate.
Q2: Are issuers required to submit separate Business Rules Templates and the Rates Table Templates for Individual and Small Group plans?
  • No. In the Rates Table template, issuers can submit rate information for individual market plans and SHOP market plans within the same template. If the issuer is offering plans with individual age rating and plans with family tier rating, the issuer should place these sets of plans on separate tabs of the template.  In the Business Rules template, issuers can submit information for individual and SHOP market plans within the same template, as long as these plans are differentiated within the template at either the product or plan level.
Q3: Can the Business Rules Template support two separate dependent ages for a Small Business Health Options Program (SHOP) Qualified Health Plan (QHP), specifically in Column F, which asks the question: "Is there a maximum age for a dependent?"
  • In the Business Rules template an issuer can define the maximum age for a dependent at the issuer-level, product-level or plan-level. The template allows for the entry of multiple products or plans which differ in values for maximum age of a dependent, as long as the products and plans are differentiated below the issuer-level row of the template. Multiple entries can be made regardless of whether the product or plan is a QHP or SADP, or is offered in the individual market or SHOP market.
Q4: If an issuer lists "Brother or Sister" as an allowed relationship on the Business Rules Template, can the issuer apply an age limit to the relationship (only brothers and sisters under a specified age allowed)?
  • An issuer can apply an age limit in the Business Rules Template for the “Brother or Sister” relationship for plans with a value of “Allows Adult and Child-Only” or “Allows Adult-Only,” as defined in the Child-Only Offering field of the Plans & Benefits Template. For plans with a value of “Allows Child-Only” (e.g., child-only plans), enrollment is limited to age 0-20 at the time of enrollment for a QHP, and age 0-18 for an SADP. As such, a covered “Brother or Sister” in a child-only plan must be within the eligible age limit for a child-only QHP or SADP.