Business Rules FAQs

Q1: In what circumstance would tobacco rates not display to a smoker?
  • 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 Rates Table Templates for Individual and Small Group plans?
  • No. In the Rates Table Template, issuers can submit rate data for Individual Market plans and SHOP Market plans within the same template. If an issuer is offering plans with age-based rates as well as plans with family-tier rates, the issuer must place these 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. If any business rule differs between an Individual and SHOP Market plan, the issuer must differentiate these as separate business rules at the product or plan level.
Q3: 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. An issuer can enter a value for the field “Is there a maximum age for a dependent?” which defines the maximum age for a dependent who can enroll within the same policy as the primary subscriber, including the “Brother or Sister” relationship if this dependent relationship is allowed.

    For plans with a value of “Allows Child-Only” (e.g., child-only plans), enrollment is limited to ages 0-20 at the time of enrollment for a QHP, and ages 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.