[Federal Register Volume 79, Number 205 (Thursday, October 23, 2014)]
[Proposed Rules]
[Pages 63363-63376]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-25257]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 600

[CMS-2391-PN]
RIN 0938-ZB18


Basic Health Program; Federal Funding Methodology for Program 
Year 2016

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed methodology.

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SUMMARY: This document provides the methodology and data sources 
necessary to determine federal payment amounts made in program year 
2016 to states that elect to establish a Basic Health Program under the 
Affordable Care Act to offer health benefits coverage to low-income 
individuals otherwise eligible to purchase coverage through Affordable 
Insurance Exchanges.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on November 24, 
2014.

ADDRESSES: In commenting, refer to file code CMS-2391-PN. Because of 
staff and resource limitations, we cannot accept comments by facsimile 
(FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address ONLY:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-2391-PN, P.O. Box 8016, Baltimore, MD 
21244-8016.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-2391-PN, Mail Stop C4-26-05, 7500 
Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. Alternatively, you may deliver (by hand or 
courier) your written ONLY to the following addresses:
a. For delivery in Washington, DC--
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Room 445-G, Hubert H. Humphrey Building, 200 
Independence Avenue SW., Washington, DC 20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
b. For delivery in Baltimore, MD--
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
call telephone number (410) 786-7195 in advance to schedule your 
arrival with one of our staff members.
    Comments erroneously mailed to the addresses indicated as 
appropriate for hand or courier delivery may be delayed and received 
after the comment period.
    Submission of comments on paperwork requirements. You may submit 
comments on this document's paperwork requirements by following the 
instructions at the end of the ``Collection of Information 
Requirements'' section in this document.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Christopher Truffer, (410) 786-1264; 
Stephanie Kaminsky, (410) 786-4653.

SUPPLEMENTARY INFORMATION:
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to 
view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday

[[Page 63364]]

through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an 
appointment to view public comments, phone 1-800-743-3951.

Table of Contents

I. Background
II. Provisions of the Proposed Methodology
    A. Overview of the Funding Methodology and Calculation of the 
Federal Payment Amount
    B. Federal BHP Payment Rate Cells
    C. Sources and State Data Considerations
    D. Discussion of Specific Variables Used in Payment Equations
    E. Adjustments for American Indians and Alaska Natives
    F. State Option to Use 2015 QHP Premiums for BHP Payments
    G. State Option to Include Retrospective State-Specific Health 
Risk Adjustment in Certified Methodology
    H. Example Application of the BHP Funding Methodology
III. Collection of Information
IV. Response to Comments
V. Regulatory Impact Statement
    A. Overall Impact
    B. Unfunded Mandates Reform Act
    C. Regulatory Flexibility Act
    D. Federalism

I. Background

    The Patient Protection and Affordable Care Act (Pub. L. 111-148, 
enacted on March 23, 2010), together with the Health Care and Education 
Reconciliation Act of 2010 (Pub. L. 111-152, enacted on March 30, 2010) 
(collectively referred as the Affordable Care Act) provides for the 
establishment of Affordable Insurance Exchanges (Exchanges, also called 
the Health Insurance Marketplace) that provide access to affordable 
health insurance coverage offered by qualified health plans (QHPs) for 
most individuals who are not eligible for health coverage under other 
federally supported health benefits programs or through affordable 
employer-sponsored insurance coverage, and who have incomes above 100 
percent but no more than 400 percent of the federal poverty line (FPL), 
or whose income is below that level but are lawfully present non-
citizens ineligible for Medicaid because of immigration status. 
Individuals enrolled through Exchanges in coverage offered by QHPs may 
qualify for the federal premium tax credit (PTC) or federally-funded 
cost-sharing reductions (CSRs) based on their household income, to make 
coverage affordable.
    In the states that elect to operate a Basic Health Program (BHP), 
BHP will make affordable health benefits coverage available for 
individuals under age 65 with household incomes between 133 percent and 
200 percent of the FPL who are not otherwise eligible for Medicaid, the 
Children's Health Insurance Program (CHIP), or affordable employer-
sponsored coverage. (For those states that have expanded Medicaid 
coverage under section 1902(a)(10)(A)(i)(VIII) of the Act, the lower 
income threshold for BHP eligibility is effectively 138 percent due to 
the application of a required 5 percent income disregard in determining 
the upper limits of Medicaid income eligibility (section 1902(e)(14)(I) 
of the Social Security Act).) Federal funding will be available for BHP 
based on the amount of PTC and CSRs that BHP enrollees would have 
received had they been enrolled in QHPs through Exchanges.
    In the March 12, 2014 Federal Register (79 FR 14112), we published 
a final rule entitled the ``Basic Health Program: State Administration 
of Basic Health Programs; Eligibility and Enrollment in Standard Health 
Plans; Essential Health Benefits in Standard Health Plans; Performance 
Standards for Basic Health Programs; Premium and Cost Sharing for Basic 
Health Programs; Federal Funding Process; Trust Fund and Financial 
Integrity'' (hereinafter referred to as the BHP final rule) 
implementing section 1331 of the Affordable Care Act), which directs 
the establishment of BHP. The BHP final rule establishes the standards 
for state and federal administration of BHP, including provisions 
regarding eligibility and enrollment, benefits, cost-sharing 
requirements and oversight activities. While the BHP final rule 
codifies the overall statutory requirements and basic procedural 
framework for the funding methodology, it does not contain the specific 
information necessary to determine federal payments. We anticipated 
that the methodology would be based on data and assumptions that would 
reflect ongoing operations and experience of BHP programs as well as 
the operation of the Exchanges. For this reason, the BHP final rule 
indicated that the development and publication of the funding 
methodology, including any data sources, would be addressed in a 
separate annual BHP Payment Notice.
    In the BHP final rule, we specified that the BHP Payment Notice 
process would include the annual publication of both a proposed and 
final BHP Payment Notice. The proposed BHP Payment Notice would be 
published in the Federal Register each October, and would describe the 
proposed methodology for the upcoming BHP program year, including how 
the Secretary considered the factors specified in section 1331(d)(3) of 
the Affordable Care Act, along with the proposed data sources used to 
determine the federal BHP payment rates. The final BHP Payment Notice 
would be published in the Federal Register in February, and would 
include the final BHP funding methodology, as well as the federal BHP 
payment rates for the next BHP program year. For example, payment rates 
published in February 2015 would apply to BHP program year 2016, 
beginning in January 2016. As discussed in section II.C of this 
proposed methodology, state data needed to calculate the federal BHP 
payment rates for the final BHP Payment Notice must be submitted to 
CMS.
    As described in the BHP final rule, once the final methodology has 
been published, we will only make modifications to the BHP funding 
methodology on a prospective basis with limited exceptions. The BHP 
final rule provided that retrospective adjustments to the state's BHP 
payment amount may occur to the extent that the prevailing BHP funding 
methodology for a given program year permits adjustments to a state's 
federal BHP payment amount due to insufficient data for prospective 
determination of the relevant factors specified in the payment notice. 
Additional adjustments could be made to the payment rates to correct 
errors in applying the methodology (such as mathematical errors).
    Under section 1331(d)(3)(ii) of the Affordable Care Act, the 
funding methodology and payment rates are expressed as an amount per 
BHP enrollee for each month of enrollment. These payment rates may vary 
based on categories or classes of enrollees. Actual payment to a state 
would depend on the actual enrollment in coverage through the state 
BHP. A state that is approved to implement BHP must provide data 
showing quarterly enrollment in the various federal BHP payment rate 
cells. The data submission requirements associated with this will be 
published subsequent to the proposed methodology.
    In the March 12, 2014 Federal Register (79 FR 13887), we published 
the final payment methodology entitled ``Basic Health Program; Federal 
Funding Methodology for Program Year 2015'' (hereinafter referred to as 
the 2015 payment methodology) that sets forth the methodology that will 
be used to calculate the federal BHP payments for the 2015 program 
year.

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II. Provisions of the Proposed Methodology

A. Overview of the Funding Methodology and Calculation of the Payment 
Amount

    Section 1331(d)(3) of the Affordable Care Act directs the Secretary 
to consider several factors when determining the federal BHP payment 
amount, which, as specified in the statute, must equal 95 percent of 
the value of the PTC and CSRs that BHP enrollees would have been 
provided had they enrolled in a QHP through an Exchange. Thus, the 
proposed BHP funding methodology is designed to calculate the PTC and 
CSRs as consistently as possible and in general alignment with the 
methodology used by Exchanges to calculate the advance payments of the 
PTC and CSRs, and by the Internal Revenue Service (IRS) to calculate 
final PTCs. In general, we propose to rely on values for factors in the 
payment methodology specified in statute or other regulations as 
available, and we propose to develop values for other factors not 
otherwise specified in statute, or previously calculated in other 
regulations, to simulate the values of the PTC and CSRs that BHP 
enrollees would have received if they had enrolled in QHPs offered 
through an Exchange. In accordance with section 1331(d)(3)(A)(iii) of 
the Affordable Care Act, the final funding methodology must be 
certified by the Chief Actuary of CMS, in consultation with the Office 
of Tax Analysis of the Department of the Treasury, as having met the 
requirements of section 1331(d)(3)(A)(ii) of the Affordable Care Act.
    Section 1331(d)(3)(A)(ii) of the Affordable Care Act specifies that 
the payment determination ``shall take into account all relevant 
factors necessary to determine the value of the premium tax credits and 
cost-sharing reductions that would have been provided to eligible 
individuals . . . including the age and income of the enrollee, whether 
the enrollment is for self-only or family coverage, geographic 
differences in average spending for health care across rating areas, 
the health status of the enrollee for purposes of determining risk 
adjustment payments and reinsurance payments that would have been made 
if the enrollee had enrolled in a qualified health plan through an 
Exchange, and whether any reconciliation of the credit or cost-sharing 
reductions would have occurred if the enrollee had been so enrolled.'' 
The proposed payment methodology takes each of these factors into 
account. We propose a methodology that is the same as the 2015 payment 
methodology, with updated values but no changes in methods.
    We propose that the total federal BHP payment amount would be based 
on multiple ``rate cells'' in each state. Each ``rate cell'' would 
represent a unique combination of age range, geographic area, coverage 
category (for example, self-only or two-adult coverage through BHP), 
household size, and income range as a percentage of FPL. Thus, there 
would be distinct rate cells for individuals in each coverage category 
within a particular age range who reside in a specific geographic area 
and are in households of the same size and income range. We note that 
we would develop BHP payment rates that would be consistent with those 
states' rules on age rating. Thus, in the case of a state that does not 
use age as a rating factor on the Exchange, the BHP payment rates would 
not vary by age.
    The proposed rate for each rate cell would be calculated in two 
parts. The first part (as described in Equation (1) below) would equal 
95 percent of the estimated PTC that would have been paid if a BHP 
enrollee in that rate cell had instead enrolled in a QHP in the 
Exchange. The second part (as described in Equation (2) below) would 
equal 95 percent of the estimated CSR payment that would have been made 
if a BHP enrollee in that rate cell had instead enrolled in a QHP in 
the Exchange. These 2 parts would be added together and the total rate 
for that rate cell would be equal to the sum of the PTC and CSR rates.
    We propose that Equation (1) below would be used to calculate the 
estimated PTC for individuals in each rate cell and Equation (2) below 
would be used to calculate the estimated CSR payments for individuals 
in each rate cell. By applying the equations separately to rate cells 
based on age, income and other factors, we would effectively take those 
factors into account in the calculation. In addition, the equations 
would reflect the estimated experience of individuals in each rate cell 
if enrolled in coverage through the Exchange, taking into account 
additional relevant variables. Each of the variables in the equations 
is defined below, and further detail is provided later in this section 
of the payment notice.
    In addition, we describe how we propose to calculate the adjusted 
reference premium (described later in this section of the payment 
notice) that is used in Equations (1) and (2). This is defined below in 
Equation (3a) and Equation (3b).
1. Equation 1: Estimated PTC by Rate Cell
    We propose that the estimated PTC, on a per enrollee basis, would 
be calculated for each rate cell for each state based on age range, 
geographic area, coverage category, household size, and income range. 
The PTC portion of the rate would be calculated in a manner consistent 
with the methodology used to calculate the PTC for persons enrolled in 
a QHP, with 3 adjustments. First, the PTC portion of the rate for each 
rate cell would represent the mean, or average, expected PTC that all 
persons in the rate cell would receive, rather than being calculated 
for each individual enrollee. Second, the reference premium used to 
calculate the PTC (described in more detail later in the section) would 
be adjusted for BHP population health status, and in the case of a 
state that elects to use 2015 premiums for the basis of the BHP federal 
payment, for the projected change in the premium from the 2015 to 2016, 
to which the rates announced in the final payment methodology would 
apply. These adjustments are described in Equation (3a) and Equation 
(3b) below. Third, the PTC would be adjusted prospectively to reflect 
the mean, or average, net expected impact of income reconciliation on 
the combination of all persons enrolled in BHP; this adjustment, as 
described in section II.D.5. of this proposed methodology, would 
account for the impact on the PTC that would have occurred had such 
reconciliation been performed. Finally, the rate is multiplied by 95 
percent, consistent with section 1331(d)(3)(A)(i) of the Affordable 
Care Act. We note that in the situation where the average income 
contribution of an enrollee would exceed the adjusted reference 
premium, we would calculate the PTC to be equal to 0 and would not 
allow the value of the PTC to be negative.
    We propose using Equation (1) to calculate the PTC rate, consistent 
with the methodology described above:
[GRAPHIC] [TIFF OMITTED] TP23OC14.003


[[Page 63366]]


PTCa,g,c,h,i = Premium tax credit portion of BHP payment rate
a = Age range
g = Geographic area
c = Coverage status (self-only or applicable category of family 
coverage) obtained through BHP
h = Household size
i = Income range (as percentage of FPL)
ARPa,g,c = Adjusted reference premium
Ih,i,j = Income (in dollars per month) at each 1 percentage-point 
increment of FPL
j = jth percentage-point increment FPL
n = Number of income increments used to calculate the mean PTC
PTCFh,i,j = Premium Tax Credit Formula percentage
IRF = Income reconciliation factor
2. Equation 2: Estimated CSR Payment by Rate Cell
    We propose that the CSR portion of the rate would be calculated for 
each rate cell for each state based on age range, geographic area, 
coverage category, household size, and income range defined as a 
percentage of FPL. The CSR portion of the rate would be calculated in a 
manner consistent with the methodology used to calculate the CSR 
advance payments for persons enrolled in a QHP, as described in the 
final rule we published in the Federal Register on March 11, 2014 
entitled ``HHS Notice of Benefit and Payment Parameters for 2015'' 
final rule (79 FR 13744), with 3 principal adjustments. (We further 
propose a separate calculation that includes different adjustments for 
American Indian/Alaska Native BHP enrollees, as described in section 
II.D.1 of this proposed methodology.) For the first adjustment, the CSR 
rate, like the PTC rate, would represent the mean expected CSR subsidy 
that would be paid on behalf of all persons in the rate cell, rather 
than being calculated for each individual enrollee. Second, this 
calculation would be based on the adjusted reference premium, as 
described in section II.A.3. of this proposed methodology. Third, this 
equation uses an adjusted reference premium that reflects premiums 
charged to non-tobacco users, rather than the actual premium that is 
charged to tobacco users to calculate CSR advance payments for tobacco 
users enrolled in a QHP. Accordingly, we propose that the equation 
include a tobacco rating adjustment factor that would account for BHP 
enrollees' estimated tobacco-related health costs that are outside the 
premium charged to non-tobacco-users. Finally, the rate would be 
multiplied by 95 percent, as provided in section 1331(d)(3)(A)(i) of 
the Affordable Care Act.
    We propose using Equation (2) to calculate the CSR rate, consistent 
with the methodology described above:
[GRAPHIC] [TIFF OMITTED] TP23OC14.004

CSRa,g,c,h,i = Cost-sharing reduction subsidy portion of BHP payment 
rate
a = Age range
g = Geographic area
c = Coverage status (self-only or applicable category of family 
coverage) obtained through BHP
h = Household size
i = Income range (as percentage of FPL)
ARPa,g,c = Adjusted reference premium
TRAF = Tobacco rating adjustment factor
FRAC = Factor removing administrative costs
AV = Actuarial value of plan (as percentage of allowed benefits 
covered by the applicable QHP without a cost-sharing reduction 
subsidy)
IUFh,i = Induced utilization factor
[Delta]AVh,i = Change in actuarial value (as percentage of allowed 
benefits)
3. Equation 3a and Equation 3b: Adjusted Reference Premium Variable 
(Used in Equations 1 and 2)
    As part of these calculations for both the PTC and CSR components, 
we propose to calculate the value of the adjusted reference premium as 
described below. Consistent with the approach last year, we are 
proposing to allow states to choose between using the actual 2016 QHP 
premiums or the 2015 QHP premiums multiplied by the premium trend 
factor (as described in section II.F). Therefore, we are proposing how 
we would calculate the adjusted reference premium under each option.
    In the case of a state that elected to use the reference premium 
based on the 2016 premiums, we propose to calculate the value of the 
adjusted reference premium as specified in Equation (3a). The adjusted 
reference premium would be equal to the reference premium, which would 
be based on the second lowest cost silver plan premium in 2016, 
multiplied by the BHP population health factor (described in section 
II.D of this proposed methodology), which would reflect the projected 
impact that enrolling BHP-eligible individuals in QHPs on an Exchange 
would have had on the average QHP premium.
[GRAPHIC] [TIFF OMITTED] TP23OC14.005

ARPa,g,c = Adjusted reference premium
a = Age range
g = Geographic area
c = Coverage status (self-only or applicable category of family 
coverage) obtained through BHP
RPa,g,c = Reference premium
PHF = Population health factor

    In the case of a state that elected to use the reference premium 
based on the 2015 premiums (as described in section II.F of this 
proposed methodology), we propose to calculate the value of the 
adjusted reference premium as specified in Equation (3b). The adjusted 
reference premium would be equal to the reference premium, which would 
be based on the second lowest cost silver plan premium in 2015, 
multiplied by the BHP population health factor (described in section 
II.D of this proposed methodology), which would reflect the projected 
impact that enrolling BHP-eligible individuals in QHPs on an Exchange 
would have had on the average QHP premium, and by the premium trend 
factor, which would reflect the projected change in the premium level 
between 2015 and 2016 (including the estimated impact of changes 
resulting from the transitional reinsurance program established in 
section 1341 of the Affordable Care Act).
[GRAPHIC] [TIFF OMITTED] TP23OC14.006


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ARPa,g,c = Adjusted reference premium
a = Age range
g = Geographic area
c = Coverage status (self-only or applicable category of family 
coverage) obtained through BHP
RPa,g,c = Reference premium
PHF = Population health factor
PTF = Premium trend factor
4. Equation 4: Determination of Total Monthly Payment for BHP Enrollees 
in Each Rate Cell
    In general, the rate for each rate cell would be multiplied by the 
number of BHP enrollees in that cell (that is, the number of enrollees 
that meet the criteria for each rate cell) to calculate the total 
monthly BHP payment. This calculation is shown in Equation 4 below.
[GRAPHIC] [TIFF OMITTED] TP23OC14.007

PMT = Total monthly BHP payment
PTCa,g,c,h,i = Premium tax credit portion of BHP payment rate
CSRa,g,c,h,i = Cost-sharing reduction subsidy portion of BHP payment 
rate
Ea,g,c,h,i = Number of BHP enrollees
a = Age range
g = Geographic area
c = Coverage status (self-only or applicable category of family 
coverage) obtained through BHP
h = Household size
i = Income range (as percentage of FPL)

B. Federal BHP Payment Rate Cells

    We propose that a state implementing BHP provide us an estimate of 
the number of BHP enrollees it projects will enroll in the upcoming BHP 
program year, by applicable rate cell, prior to the first quarter of 
program operations. Upon our approval of such estimates as reasonable, 
they would be used to calculate the prospective payment for the first 
and subsequent quarters of program operation until the state has 
provided us actual enrollment data. These data would be required to 
calculate the final BHP payment amount, and make any necessary 
reconciliation adjustments to the prior quarters' prospective payment 
amounts due to differences between projected and actual enrollment. 
Subsequent, quarterly deposits to the state's trust fund would be based 
on the most recent actual enrollment data submitted to us. Procedures 
will ensure that federal payments to a state reflect actual BHP 
enrollment during a year, within each applicable category, and 
prospectively determined federal payment rates for each category of BHP 
enrollment, with such categories defined in terms of age range, 
geographic area, coverage status, household size, and income range, as 
explained above.
    We propose requiring the use of certain rate cells as part of the 
proposed methodology. For each state, we propose using rate cells that 
separate the BHP population into separate cells based on the five 
factors described below.
    Factor 1--Age: We propose separating enrollees into rate cells by 
age, using the following age ranges that capture the widest variations 
in premiums under HHS's Default Age Curve: \1\
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    \1\ This curve is used to implement the Affordable Care Act's 
3:1 limit on age-rating in states that do not create an alternative 
rate structure to comply with that limit. The curve applies to all 
individual market plans, both within and outside the Exchange. The 
age bands capture the principal allowed age-based variations in 
premiums as permitted by this curve. More information can be found 
at http://www.cms.gov/CCIIO/Resources/Files/Downloads/market-reforms-guidance-2-25-2013.pdf. Both children and adults under age 
21 are charged the same premium. For adults age 21-64, the age bands 
in this methodology divide the total age-based premium variation 
into the three most equally-sized ranges (defining size by the ratio 
between the highest and lowest premiums within the band) that are 
consistent with the age-bands used for risk-adjustment purposes in 
the HHS-Developed Risk Adjustment Model. For such age bands, see 
Table 5, ``Age-Sex Variables,'' in HHS-Developed Risk Adjustment 
Model Algorithm Software, June 2, 2014, http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/ra-tables-03-27-2014.xlsx.
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     Ages 0-20.
     Ages 21-34.
     Ages 35-44.
     Ages 45-54.
     Ages 55-64.
    Factor 2--Geographic area: For each state, we propose separating 
enrollees into rate cells by geographic areas within which a single 
reference premium is charged by QHPs offered through the state's 
Exchange. Multiple, non-contiguous geographic areas would be 
incorporated within a single cell, so long as those areas share a 
common reference premium.\2\
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    \2\ For example, a cell within a particular state might refer to 
``County Group 1,'' ``County Group 2,'' etc., and a table for the 
state would list all the counties included in each such group. These 
geographic areas are consistent with the geographic areas 
established under the 2014 Market Reform Rules. They also reflect 
the service area requirements applicable to qualified health plans, 
as described in 45 CFR 155.1055, except that service areas smaller 
than counties are addressed as explained below.
---------------------------------------------------------------------------

    Factor 3--Coverage status: We propose separating enrollees into 
rate cells by coverage status, reflecting whether an individual is 
enrolled in self-only coverage or persons are enrolled in family 
coverage through BHP, as provided in section 1331(d)(3)(A)(ii) of the 
Affordable Care Act. Among recipients of family coverage through BHP, 
separate rate cells, as explained below, would apply based on whether 
such coverage involves two adults alone or whether it involves 
children.
    Factor 4--Household size: We propose separating enrollees into rate 
cells by household size that states use to determine BHP enrollees' 
income as a percentage of the FPL under proposed 42 CFR 600.320. We are 
proposing to require separate rate cells for several specific household 
sizes. For each additional member above the largest specified size, we 
propose to publish instructions for how we would develop additional 
rate cells and calculate an appropriate payment rate based on data for 
the rate cell with the closest specified household size. We propose to 
publish separate rate cells for household sizes of 1, 2, 3, 4, and 5, 
as unpublished analyses of American Community Survey data conducted by 
the Urban Institute, which take into account unaccepted offers of 
employer-sponsored insurance as well as income, Medicaid and CHIP 
eligibility, citizenship and immigration status, and current health 
coverage status, find that less than 1 percent of all BHP-eligible 
persons live in households of size 5 or greater.
    Factor 5--Income: For households of each applicable size, we 
propose creating separate rate cells by income range, as a percentage 
of FPL. The PTC that a person would receive if enrolled in a QHP varies 
by income, both in level and as a ratio to the FPL, and the CSR varies 
by income as a percentage of FPL. Thus, we propose that separate rate 
cells would be used to calculate federal BHP payment rates to reflect 
different bands of income measured as a percentage of FPL. We propose 
using the following income ranges, measured as a ratio to the FPL:
     0 to 50 percent of the FPL.
     51 to 100 percent of the FPL.
     101 to 138 percent of the FPL.\3\
---------------------------------------------------------------------------

    \3\ The three lowest income ranges would be limited to lawfully 
present immigrants who are ineligible for Medicaid because of 
immigration status.

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[[Page 63368]]

     139 to 150 percent of the FPL.
     151 to 175 percent of the FPL.
     176 to 200 percent of the FPL.
    These rate cells would only be used to calculate the federal BHP 
payment amount. A state implementing BHP would not be required to use 
these rate cells or any of the factors in these rate cells as part of 
the state payment to the standard health plans participating in BHP or 
to help define BHP enrollees' covered benefits, premium costs, or out-
of-pocket cost-sharing levels.
    We propose using averages to define federal payment rates, both for 
income ranges and age ranges, rather than varying such rates to 
correspond to each individual BHP enrollee's age and income level. We 
believe that the proposed approach will increase the administrative 
feasibility of making federal BHP payments and reduce the likelihood of 
inadvertently erroneous payments resulting from highly complex 
methodologies. We believe that this approach should not significantly 
change federal payment amounts, since within applicable ranges, the 
BHP-eligible population is distributed relatively evenly.

C. Sources and State Data Considerations

    To the extent possible, we intend to use data submitted to the 
federal government by QHP issuers seeking to offer coverage through an 
Exchange to perform the calculations that determine federal BHP payment 
cell rates.
    States operating a State Based Exchange in the individual market, 
however, must provide certain data, including premiums for second 
lowest cost silver plans, by geographic area, in order for CMS to 
calculate the federal BHP payment rates in those states. We propose 
that a State Based Exchange interested in obtaining the applicable 
federal BHP payment rates for its state must submit such data 
accurately, completely, and as specified by CMS, by no later than 
October 15, 2015, in order for CMS to calculate the applicable rates 
for 2016. If additional state data (that is, in addition to the second 
lowest cost silver plan premium data) are needed to determine the 
federal BHP payment rate, such data must be submitted in a timely 
manner, and in a format specified by CMS to support the development and 
timely release of annual BHP payment notices. The specifications for 
data collection to support the development of BHP payment rates for 
2016 were published in CMS guidance and are available at http://www.medicaid.gov/Federal-Policy-Guidance/Federal-Policy-Guidance.html.
    If a state operating a State Based Exchange provides the necessary 
data accurately, completely, and as specified by CMS, but after the 
date specified above, we anticipate publishing federal payment rates 
for such a state in a subsequent Payment Notice. As noted in the BHP 
final rule, a state may elect to implement its BHP after a program year 
has begun. In such an instance, we propose that the state, if operating 
a State Based Exchange, submit its data no later than 30 days after the 
Blueprint submission for CMS to calculate the applicable federal 
payment rates. We further propose that the BHP Blueprint itself must be 
submitted for Secretarial certification with an effective date of no 
sooner than 120 days after submission of the BHP Blueprint. In 
addition, the state must ensure that its Blueprint includes a detailed 
description of how the state will coordinate with other insurance 
affordability programs to transition and transfer BHP-eligible 
individuals out of their existing QHP coverage, consistent with the 
requirements set forth in 42 CFR 600.330 and 600.425. We believe that 
this 120-day period is necessary to establish the requisite 
administrative structures and ensure that all statutory and regulatory 
requirements are satisfied.

D. Discussion of Specific Variables Used in Payment Equations

1. Reference Premium (RP)
    To calculate the estimated PTC that would be paid if individuals 
enrolled in QHPs through the Exchange, we must calculate a reference 
premium (RP) because the PTC is based, in part, on the premiums for the 
applicable second lowest cost silver plan as explained in section 
II.C.4 of this proposed methodology, regarding the Premium Tax Credit 
Formula (PTCF). Accordingly, for the purposes of calculating the BHP 
payment rates, the reference premium, in accordance with 26 U.S.C. 
36B(b)(3)(C), is defined as the adjusted monthly premium for an 
applicable second lowest cost silver plan. The applicable second lowest 
cost silver plan is defined in 26 U.S.C. 36B(b)(3)(B) as the second 
lowest cost silver plan of the individual market in the rating area in 
which the taxpayer resides, which is offered through the same Exchange. 
We propose to use the adjusted monthly premium for an applicable second 
lowest cost silver plan in 2016 as the reference premium (except in the 
case of a state that elects to use the 2015 premium as the basis for 
the federal BHP payment, as described in section II.F of this proposed 
methodology).
    The reference premium would be the premium applicable to non-
tobacco users. This is consistent with the provision in 26 U.S.C. 
36B(b)(3)(C) that bases the PTC on premiums that are adjusted for age 
alone, without regard to tobacco use, even for states that allow 
insurers to vary premiums based on tobacco use pursuant to 42 U.S.C. 
300gg(a)(1)(A)(iv).
    Consistent with the policy set forth in 26 CFR 1.36B-3(f)(6) to 
calculate the PTC for those enrolled in a QHP through an Exchange, we 
propose not to update the payment methodology, and subsequently the 
federal BHP payment rates, in the event that the second lowest cost 
silver plan used as the reference premium, or the lowest cost silver 
plan, changes (that is, terminates or closes enrollment during the 
year).
    The applicable second lowest cost silver plan premium will be 
included in the BHP payment methodology by age range, geographic area, 
and self-only or applicable category of family coverage obtained 
through BHP.
    American Indians and Alaska Natives in households with incomes 
below 300 percent of the FPL are eligible for a full cost sharing 
subsidy regardless of the plan they select (as described in sections 
1402(d) and 2901(a) of the Affordable Care Act). We assume that 
American Indians and Alaska Natives would be more likely to enroll in 
bronze plans as a result; thus, for American Indian/Alaska Native BHP 
enrollees, we propose to use the lowest cost bronze plan as the basis 
for the reference premium for the purposes of calculating the CSR 
portion of the federal BHP payment as described further in section II.E 
of this proposed methodology.
    We would note that the choice of the second lowest cost silver plan 
for calculating BHP payments would rely on several simplifying 
assumptions in its selection. For the purposes of determining the 
second lowest cost silver plan for calculating PTC for a person 
enrolled in a QHP through an Exchange, the applicable plan may differ 
for various reasons. For example, a different second lowest cost silver 
plan may apply to a family consisting of two adults, their child, and 
their niece than to a family with 2 adults and their children, because 
1 or more QHPs in the family's geographic area might not offer family 
coverage that includes the niece. We believe that it would not be 
possible to replicate such variations for calculating the BHP payment 
and believe that in aggregate they would not result in a significant 
difference in the payment. Thus, we propose to use the

[[Page 63369]]

second lowest cost silver plan available to any enrollee for a given 
age, geographic area, and coverage category.
    This choice of reference premium relies on 2 assumptions about 
enrollment in the Exchanges. First, we assume that all persons enrolled 
in BHP would have elected to enroll in a silver level plan if they had 
instead enrolled in a QHP through the Exchanges. It is possible that 
some persons would have chosen not to enroll at all or would have 
chosen to enroll in a different metal-level plan (in particular, a 
bronze level plan with a premium that is less than the PTC for which 
the person was eligible). We do not believe it is appropriate to adjust 
the payment for an assumption that some BHP enrollees would not have 
enrolled in QHPs for purposes of calculating the BHP payment rates, 
since Affordable Care Act section 1331(d)(3)(A)(ii) requires the 
calculation of such rates as ``if the enrollee had enrolled in a 
qualified health plan through an Exchange.''
    Second, we assume that, among all available silver plans, all 
persons enrolled in BHP would have selected the second-lowest cost 
plan. Both this and the prior assumption allow an administratively 
feasible determination of federal payment levels. They also have some 
implications for the CSR portion of the rate. If persons were to enroll 
in a bronze level plan through the Exchange, they would not be eligible 
for CSRs, unless they were an eligible American Indian or Alaska 
Native; thus, assuming that all persons enroll in a silver level plan, 
rather than a plan with a different metal level, would increase the BHP 
payment. Assuming that all persons enroll in the second lowest cost 
silver plan for the purposes of calculating the CSR portion of the rate 
may result in a different level of CSR payments than would have been 
paid if the persons were enrolled in different silver level plans on 
the Exchanges (with either lower or higher premiums). We believe it 
would not be reasonable at this point to estimate how BHP enrollees 
would have enrolled in different silver level QHPs, and thus propose to 
use the second lowest cost silver plan as the basis for the reference 
premium and calculating the CSR portion of the rate. For American 
Indian/Alaska Native BHP enrollees, we propose to use the lowest cost 
bronze plan as the basis for the reference premium as described further 
in section II.E. of this proposed methodology.
    The applicable age bracket will be one dimension of each rate cell. 
We propose to assume a uniform distribution of ages and estimate the 
average premium amount within each rate cell. We believe that assuming 
a uniform distribution of ages within these ranges is a reasonable 
approach and would produce a reliable determination of the PTC and CSR 
components. We also believe this approach would avoid potential 
inaccuracies that could otherwise occur in relatively small payment 
cells if age distribution were measured by the number of persons 
eligible or enrolled.
    We propose to use geographic areas based on the rating areas used 
in the Exchanges. We propose to define each geographic area so that the 
reference premium is the same throughout the geographic area. When the 
reference premium varies within a rating area, we propose defining 
geographic areas as aggregations of counties with the same reference 
premium. Although plans are allowed to serve geographic areas smaller 
than counties after obtaining our approval, we propose that no 
geographic area, for purposes of defining BHP payment rate cells, will 
be smaller than a county. We do not believe that this assumption will 
have a significant impact on federal payment levels and it would likely 
simplify both the calculation of BHP payment rates and the operation of 
BHP.
    Finally, in terms of the coverage category, we propose that federal 
payment rates only recognize self-only and two-adult coverage, with 
exceptions that account for children who are potentially eligible for 
BHP. First, in states that set the upper income threshold for 
children's Medicaid and CHIP eligibility below 200 percent of FPL 
(based on modified adjusted gross income), children in households with 
incomes between that threshold and 200 percent of FPL would be 
potentially eligible for BHP. Currently, the only states in this 
category are Arizona, Idaho, and North Dakota.\4\ Second, BHP would 
include lawfully present immigrant children with incomes at or below 
200 percent of FPL in states that have not exercised the option under 
the sections 1903(v)(4)(A)(ii) and 2107(e)(1)(E) of the Social Security 
Act (the Act) to qualify all otherwise eligible, lawfully present 
immigrant children for Medicaid and CHIP. States that fall within these 
exceptions would be identified based on their Medicaid and CHIP State 
Plans, and the rate cells would include appropriate categories of BHP 
family coverage for children. For example, Idaho's Medicaid and CHIP 
eligibility is limited to families with MAGI at or below 185 percent 
FPL. If Idaho implemented BHP, Idaho children with incomes between 185 
and 200 percent could qualify. In other states, BHP eligibility will 
generally be restricted to adults, since children who are citizens or 
lawfully present immigrants and who live in households with incomes at 
or below 200 percent of FPL will qualify for Medicaid or CHIP and thus 
be ineligible for BHP under section 1331(e)(1)(C) of the Affordable 
Care Act, which limits BHP to individuals who are ineligible for 
minimum essential coverage (as defined in section 5000A(f) of the 
Internal Revenue Code of 1986).
---------------------------------------------------------------------------

    \4\ CMCS. ``State Medicaid and CHIP Income Eligibility Standards 
Effective January 1, 2014.''
---------------------------------------------------------------------------

2. Population Health Factor (PHF)
    We propose that the population health factor be included in the 
methodology to account for the potential differences in the average 
health status between BHP enrollees and persons enrolled in the 
marketplace. To the extent that BHP enrollees would have been enrolled 
in the marketplace in the absence of BHP in a state, the inclusion of 
those BHP enrollees in the marketplace may affect the average health 
status of the overall population and the expected QHP premiums.
    We currently do not believe that there is evidence that the BHP 
population would have better or poorer health status than the 
marketplace population. At this time, there is a lack of experience 
available in the marketplace that limits the ability to analyze the 
health differences between these groups of enrollees. In addition, 
differences in population health may vary across states. Thus, at this 
time, we believe that it is not feasible to develop a methodology to 
make a prospective adjustment to the population health factor that is 
reliably accurate.
    Given these analytic challenges and the limited data about Exchange 
coverage and the characteristics of BHP-eligible consumers that will be 
available by the time we establish federal payment rates for 2016, we 
believe that the most appropriate adjustment for 2016 would be 1.00. In 
the 2015 payment methodology, we included an option for states to 
include a retrospective population health status adjustment. Similarly, 
we propose for the 2016 payment methodology to provide states with the 
same option, as described further in section II.G of this proposed 
methodology, to include a retrospective population health status 
adjustment in the certified methodology, which is subject to CMS review 
and approval. Regardless of whether a state elects to include a 
retrospective population health status adjustment, we anticipate that, 
in future

[[Page 63370]]

years, when additional data become available about Exchange coverage 
and the characteristics of BHP enrollees, we may estimate this factor 
differently.
    While the statute requires consideration of risk adjustment 
payments and reinsurance payments insofar as they would have affected 
the PTC and CSRs that would have been provided to BHP-eligible 
individuals had they enrolled in QHPs, we are not proposing to require 
that a BHP program's standard health plans receive such payments. As 
explained in the BHP final rule, BHP standard health plans are not 
included in the risk adjustment program operated by HHS on behalf of 
states. Further, standard health plans do not qualify for payments from 
the transitional reinsurance program established under section 1341 of 
the Affordable Care Act.\5\ To the extent that a state operating a BHP 
determines that, because of the distinctive risk profile of BHP-
eligible consumers, BHP standard health plans should be included in 
mechanisms that share risk with other plans in the state's individual 
market, the state would need to use other methods for achieving this 
goal.
---------------------------------------------------------------------------

    \5\ See 45 CFR 153.400(a)(2)(iv) (BHP standard health plans are 
not required to submit reinsurance contributions), 153.20 
(definition of ``Reinsurance-eligible plan'' as not including 
``health insurance coverage not required to submit reinsurance 
contributions''), 153.230(a) (reinsurance payments under the 
national reinsurance parameters are available only for 
``Reinsurance-eligible plans'').
---------------------------------------------------------------------------

3. Income (I)
    Household income is a significant determinant of the amount of the 
PTC and CSRs that are provided for persons enrolled in a QHP through 
the Exchange. Accordingly, the proposed BHP payment methodology 
incorporates income into the calculations of the payment rates through 
the use of income-based rate cells. We propose defining income in 
accordance with the definition of modified adjusted gross income in 26 
U.S.C. 36B(d)(2)(B) and consistent with the definition in 45 CFR 
155.300. Income would be measured relative to the FPL, which is updated 
periodically in the Federal Register by the Secretary under the 
authority of 42 U.S.C. 9902(2), based on annual changes in the consumer 
price index for all urban consumers (CPI-U). In our proposed 
methodology, household size and income as a percentage of FPL would be 
used as factors in developing the rate cells. We propose using the 
following income ranges measured as a percentage of FPL: \6\
---------------------------------------------------------------------------

    \6\ These income ranges and this analysis of income apply to the 
calculation of the PTC. Many fewer income ranges and a much simpler 
analysis apply in determining the value of CSRs, as specified below.
---------------------------------------------------------------------------

     0-50 percent.
     51-100 percent.
     101-138 percent.
     139-150 percent.
     151-175 percent.
     176-200 percent.
    We further propose to assume a uniform income distribution for each 
federal BHP payment cell. We believe that assuming a uniform income 
distribution for the income ranges proposed would be reasonably 
accurate for the purposes of calculating the PTC and CSR components of 
the BHP payment and would avoid potential errors that could result if 
other sources of data were used to estimate the specific income 
distribution of persons who are eligible for or enrolled in BHP within 
rate cells that may be relatively small. Thus, when calculating the 
mean, or average, PTC for a rate cell, we propose to calculate the 
value of the PTC at each one percentage point interval of the income 
range for each federal BHP payment cell and then calculate the average 
of the PTC across all intervals. This calculation would rely on the PTC 
formula described below in section II.4 of this proposed methodology.
    As the PTC for persons enrolled in QHPs would be calculated based 
on their income during the open enrollment period, and that income 
would be measured against the FPL at that time, we propose to adjust 
the FPL by multiplying the FPL by a projected increase in the CPI-U 
between the time that the BHP payment rates are published and the QHP 
open enrollment period, if the FPL is expected to be updated during 
that time. We propose that the projected increase in the CPI-U would be 
based on the intermediate inflation forecasts from the most recent 
OASDI and Medicare Trustees Reports.\7\
---------------------------------------------------------------------------

    \7\ See Table IV A1 from the 2013 reports in http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2014.pdf.
---------------------------------------------------------------------------

4. Premium Tax Credit Formula (PTCF)
    In Equation 1 described in section II.A.1 of this proposed 
methodology, we propose to use the formula described in 26 U.S.C. 
36B(b) to calculate the estimated PTC that would be paid on behalf of a 
person enrolled in a QHP on an Exchange as part of the BHP payment 
methodology. This formula is used to determine the contribution amount 
(the amount of premium that an individual or household theoretically 
would be required to pay for coverage in a QHP on an Exchange), which 
is based on (A) the household income; (B) the household income as a 
percentage of FPL for the family size; and (C) the schedule specified 
in 26 U.S.C. 36B(b)(3)(A) and shown below. The difference between the 
contribution amount and the adjusted monthly premium for the applicable 
second lowest cost silver plan is the estimated amount of the PTC that 
would be provided for the enrollee.
    The PTC amount provided for a person enrolled in a QHP through an 
Exchange is calculated in accordance with the methodology described in 
26 U.S.C. 36B(b)(2). The amount is equal to the lesser of the premium 
for the plan in which the person or household enrolls, or the adjusted 
premium for the applicable second lowest cost silver plan minus the 
contribution amount.
    The applicable percentage is defined in 26 U.S.C. 36B(b)(3)(A) and 
26 CFR 1.36B-3(g) as the percentage that applies to a taxpayer's 
household income that is within an income tier specified in the table, 
increasing on a sliding scale in a linear manner from an initial 
premium percentage to a final premium percentage specified in the table 
(see Table 1):

[[Page 63371]]



                        Table 1--Household Income
                [Expressed as a percent of poverty line]
------------------------------------------------------------------------
   In the case of household income       The initial        The final
 (expressed as a percent of poverty        premium           premium
  line) within the following income    percentage is--   percentage is--
                tier:                     (percent)         (percent)
------------------------------------------------------------------------
Up to 133%..........................              2.01              2.01
133% but less than 150%.............              3.02              4.02
150% but less than 200%.............              4.02              6.34
200% but less than 250%.............              6.34              8.10
250% but less than 300%.............              8.10              9.56
300% but not more than 400%.........              9.56              9.56
------------------------------------------------------------------------

    These are the applicable percentages for CY 2015. The applicable 
percentages will be updated in future years in accordance with 26 
U.S.C. 36B(b)(3)(A)(ii).
5. Income Reconciliation Factor (IRF)
    For persons enrolled in a QHP through an Exchange who receive an 
advance payment of the premium tax credit (APTC), there will be an 
annual reconciliation following the end of the year to compare the 
advance payments to the correct amount of PTC based on household 
circumstances shown on the federal income tax return. Any difference 
between the latter amounts and the advance payments made during the 
year would either be paid to the taxpayer (if too little APTC was paid) 
or charged to the taxpayer as additional tax (if too much APTC was 
made, subject to any limitations in statute or regulation), as provided 
in 26 U.S.C. 36B(f).
    Section 1331(e)(2) of the Affordable Care Act specifies that an 
individual enrolled in BHP may not be treated as a qualified individual 
under section 1312 eligible for enrollment in a QHP offered through an 
Exchange. Therefore, BHP enrollees are not eligible to receive APTC to 
assist with purchasing coverage in the Exchange. Because they do not 
receive APTC assistance, BHP enrollees are not subject to the same 
income reconciliation as Exchange consumers. Nonetheless, there may 
still be differences between a BHP enrollee's household income reported 
at the beginning of the year and the actual income over the year. These 
may include small changes (reflecting changes in hourly wage rates, 
hours worked per week, and other fluctuations in income during the 
year) and large changes (reflecting significant changes in employment 
status, hourly wage rates, or substantial fluctuations in income). 
There may also be changes in household composition. Thus, we believe 
that using unadjusted income as reported prior to the BHP program year 
may result in calculations of estimated PTC that are inconsistent with 
the actual incomes of BHP enrollees during the year. Even if the BHP 
program adjusts household income determinations and corresponding 
claims of federal payment amounts based on household reports during the 
year or data from third-party sources, such adjustments may not fully 
capture the effects of tax reconciliation that BHP enrollees would have 
experienced had they been enrolled in a QHP through an Exchange and 
received APTC assistance.
    Therefore, we propose including in Equation 1 an income adjustment 
factor that would account for the difference between calculating 
estimated PTC using: (a) Income relative to FPL as determined at 
initial application and potentially revised mid-year, under proposed 
600.320, for purposes of determining BHP eligibility and claiming 
federal BHP payments; and (b) actual income relative to FPL received 
during the plan year, as it would be reflected on individual federal 
income tax returns. This adjustment would seek prospectively to capture 
the average effect of income reconciliation aggregated across the BHP 
population had those BHP enrollees been subject to tax reconciliation 
after receiving APTC assistance for coverage provided through QHPs. For 
2016, we propose estimating reconciliation effects based on tax data 
for 2 years, reflecting income and tax unit composition changes over 
time among BHP-eligible individuals.
    The Office of Tax Analysis in the U.S. Department of Treasury (OTA) 
maintains a model that combines detailed tax and other data, including 
Exchange enrollment and PTC claimed, to project Exchange premiums, 
enrollment, and tax credits. For each enrollee, this model compares the 
APTC based on household income and family size estimated at the point 
of enrollment with the PTC based on household income and family size 
reported at the end of the tax year. The former reflects the 
determination using enrollee information furnished by the applicant and 
tax data furnished by the IRS. The latter would reflect the PTC 
eligibility based on information on the tax return, which would have 
been determined if the individual had not enrolled in BHP. We propose 
that the ratio of the reconciled PTC to the initial estimation of PTC 
would be used as the income reconciliation factor in Equation (1) for 
estimating the PTC portion of the BHP payment rate.
    For 2015, OTA estimated that the income reconciliation factor for 
states that have implemented the Medicaid eligibility expansion to 
cover adults up to 133 percent of the FPL will be 94.52 percent, and 
for states that have not implemented the Medicaid eligibility expansion 
and do not cover adults up to 133 percent of the FPL will be 95.32 
percent. In the 2015 payment methodology, the IRF was set equal to the 
average of these two factors (94.92 percent). We propose updating this 
analysis and the IRF for 2016.
6. Tobacco Rating Adjustment Factor (TRAF)
    As described above, the reference premium is estimated, for 
purposes of determining both the PTC and related federal BHP payments, 
based on premiums charged for non-tobacco users, including in states 
that allow premium variations based on tobacco use, as provided in 42 
U.S.C. 300gg (a)(1)(A)(iv). In contrast, as described in 45 CFR 
156.430, the CSR advance payments are based on the total premium for a 
policy, including any adjustment for tobacco use. Accordingly, we 
propose to incorporate a tobacco rating adjustment factor into Equation 
2 that reflects the average percentage increase in health care costs 
that results from tobacco use among the BHP-eligible population and 
that would not be reflected in the premium charged to non-users. This 
factor will also take into account the estimated proportion of tobacco 
users among BHP-eligible consumers.

[[Page 63372]]

    To estimate the average effect of tobacco use on health care costs 
(not reflected in the premium charged to non-users), we propose to 
calculate the ratio between premiums that silver level QHPs charge for 
tobacco users to the premiums they charge for non-tobacco users at 
selected ages. To calculate estimated proportions of tobacco users, we 
propose to use data from the Centers for Disease Control and Prevention 
to estimate tobacco utilization rates by state and relevant population 
characteristic.\8\ For each state, we propose to calculate the tobacco 
usage rate based on the percentage of persons by age who use cigarettes 
and the percentage of persons by age that use smokeless tobacco, and 
calculate the utilization rate by adding the two rates together. The 
data is available for 3 age intervals: 18-24; 25-44; and 45-64. For the 
BHP payment rate cell for persons ages 21-34, we would calculate the 
factor as (4/14 * the utilization rate of 18-24 year olds) plus (10/14 
* the utilization rate of 25-44 year olds), which would be the weighted 
average of tobacco usage for persons 21-34 assuming a uniform 
distribution of ages; for all other age ranges used for the rate cells, 
we would use the age range in the CDC data in which the BHP payment 
rate cell age range is contained.
---------------------------------------------------------------------------

    \8\ Centers for Disease Control and Prevention, Tobacco Control 
State Highlights 2012: http://www.cdc.gov/tobacco/data_statistics/state_data/state_highlights/2012/index.htm.
---------------------------------------------------------------------------

    We propose to provide tobacco rating factors that may vary by age 
and by geographic area within each state. To the extent that the second 
lowest cost silver plans have a different ratio of tobacco user rates 
to non-tobacco user rates in different geographic areas, the tobacco 
rating adjustment factor may differ across geographic areas within a 
state. In addition, to the extent that the second lowest cost silver 
plan has a different ratio of tobacco user rates to non-tobacco user 
rates by age, or that there is a different prevalence of tobacco use by 
age, the tobacco rating adjustment factor may differ by age.
7. Factor for Removing Administrative Costs (FRAC)
    The Factor for Removing Administrative Costs represents the average 
proportion of the total premium that covers allowed health benefits, 
and we propose including this factor in our calculation of estimated 
CSRs in Equation 2. The product of the reference premium and the Factor 
for Removing Administrative Costs would approximate the estimated 
amount of Essential Health Benefit (EHB) claims that would be expected 
to be paid by the plan. This step is needed because the premium also 
covers such costs as taxes, fees, and QHP administrative expenses. We 
are proposing to set this factor equal to 0.80, which is the same 
percentage for the factor to remove administrative costs for 
calculating CSR advance payments for established in the 2015 HHS Notice 
of Benefit and Payment Parameters.
8. Actuarial Value (AV)
    The actuarial value is defined as the percentage paid by a health 
plan of the total allowed costs of benefits, as defined under 45 CFR 
156.20. (For example, if the average health care costs for enrollees in 
a health insurance plan were $1,000 and that plan has an actuarial 
value of 70 percent, the plan would be expected to pay on average $700 
($1,000 x 0.70) for health care costs per enrollee, on average.) By 
dividing such estimated costs by the actuarial value in the proposed 
methodology, we would calculate the estimated amount of total EHB-
allowed claims, including both the portion of such claims paid by the 
plan and the portion paid by the consumer for in-network care. (To 
continue with that same example, we would divide the plan's expected 
$700 payment of the person's EHB-allowed claims by the plan's 70 
percent actuarial value to ascertain that the total amount of EHB-
allowed claims, including amounts paid by the consumer, is $1,000.)
    For the purposes of calculating the CSR rate in Equation 2, we 
propose to use the standard actuarial value of the silver level plans 
in the individual market, which is equal to 70 percent.
9. Induced Utilization Factor (IUF)
    The induced utilization factor is proposed as a factor in 
calculating estimated CSRs in Equation 2 to account for the increase in 
health care service utilization associated with a reduction in the 
level of cost sharing a QHP enrollee would have to pay, based on the 
cost-sharing reduction subsidies provided to enrollees.
    The 2015 HHS Notice of Benefit and Payment Parameters provided 
induced utilization factors for the purposes of calculating cost-
sharing reduction advance payments for 2015. In that rule, the induced 
utilization factors for silver plan variations ranged from 1.00 to 
1.12, depending on income. Using those utilization factors, the induced 
utilization factor for all persons who would qualify for BHP based on 
their household income as a percentage of FPL is 1.12; this would 
include persons with household income between 100 percent and 200 
percent of FPL, lawfully present non-citizens below 100 percent of FPL 
who are ineligible for Medicaid because of immigration status, and 
persons with household income under 300 percent of FPL, not subject to 
any cost-sharing. Thus, consistent with last year, we propose to set 
the induced utilization factor equal to 1.12 for the BHP payment 
methodology.
    We note that for CSRs for QHPs, there will be a final 
reconciliation at the end of the year and the actual level of induced 
utilization could differ from the factor proposed in the rule. Our 
proposed methodology for BHP funding would not include any 
reconciliation for utilization and thus may understate or overstate the 
impact of the effect of the subsidies on health care utilization.
10. Change in Actuarial Value ([Delta]AV)
    The increase in actuarial value would account for the impact of the 
cost-sharing reduction subsidies on the relative amount of EHB claims 
that would be covered for or paid by eligible persons, and we propose 
including it as a factor in calculating estimated CSRs in Equation 2.
    The actuarial values of QHPs for persons eligible for cost-sharing 
reduction subsidies are defined in 45 CFR 156.420(a), and eligibility 
for such subsidies is defined in 45 CFR 155.305(g)(2)(i) through (iii). 
For QHP enrollees with household incomes between 100 percent and 150 
percent of FPL, and those below 100 percent of FPL who are ineligible 
for Medicaid because of their immigration status, CSRs increase the 
actuarial value of a QHP silver plan from 70 percent to 94 percent. For 
QHP enrollees with household incomes between 150 percent and 200 
percent of FPL, CSRs increase the actuarial value of a QHP silver plan 
from 70 percent to 87 percent.
    We propose to apply this factor by subtracting the standard AV from 
the higher AV allowed by the applicable cost-sharing reduction. For BHP 
enrollees with household incomes at or below 150 percent of FPL, this 
factor would be 0.24 (94 percent minus 70 percent); for BHP enrollees 
with household incomes more than 150 percent but not more than 200 
percent of FPL, this factor would be 0.17 (87 percent minus 70 
percent).

E. Adjustments for American Indians and Alaska Natives

    There are several exceptions made for American Indians and Alaska 
Natives enrolled in QHPs through an Exchange to calculate the PTC and 
CSRs. Thus, we propose adjustments to the payment

[[Page 63373]]

methodology described above to be consistent with the Exchange rules.
    We propose the following adjustments:
    1. We propose that the adjusted reference premium for use in the 
CSR portion of the rate would use the lowest cost bronze plan instead 
of the second lowest cost silver plan, with the same adjustment for the 
population health factor (and in the case of a state that elects to use 
the 2015 premiums as the basis of the federal BHP payment, the same 
adjustment for the premium trend factor). American Indians and Alaska 
Natives are eligible for CSRs with any metal level plan, and thus we 
believe that eligible persons would be more likely to select a bronze 
level plan instead of a silver level plan. (It is important to note 
that this would not change the PTC, as that is the maximum possible PTC 
payment, which is always based on the applicable second lowest cost 
silver plan.)
    2. We propose that the actuarial value for use in the CSR portion 
of the rate would be 0.60 instead of 0.70, which is consistent with the 
actuarial value of a bronze level plan.
    3. We propose that the induced utilization factor for use in the 
CSR portion of the rate would be 1.15, which is consistent with the 
2015 HHS Notice of Benefit and Payment Parameters induced utilization 
factor for calculating advance CSR payments for persons enrolled in 
bronze level plans and eligible for CSRs up to 100 percent of actuarial 
value.
    4. We propose that the change in the actuarial value for use in the 
CSR portion of the rate would be 0.40. This reflects the increase from 
60 percent actuarial value of the bronze plan to 100 percent actuarial 
value, as American Indians and Alaska Natives are eligible to receive 
CSRs up to 100 percent of actuarial value.

F. State Option To Use 2015 QHP Premiums for BHP Payments

    In the interest of allowing states greater certainty in the total 
BHP federal payments for 2016, we propose providing states the option 
to have their final 2016 federal BHP payment rates calculated using the 
projected 2016 adjusted reference premium (that is, using 2015 premium 
data multiplied by the premium trend factor defined below), as 
described in Equation (3b).
    For a state that would elect to use the 2015 premium as the basis 
for the 2016 BHP federal payment, we propose requiring that the state 
inform us no later than May 15, 2015.
    For Equation (3b), we propose to define the premium trend factor as 
follows:
    Premium Trend Factor (PTF): In Equation (3b), we propose to 
calculate an adjusted reference premium (ARP) based on the application 
of certain relevant variables to the reference premium (RP), including 
a premium trend factor (PTF). In the case of a state that would elect 
to use the 2015 premiums as the basis for determining the BHP payment, 
it would be appropriate to apply a factor that would account for the 
change in health care costs between the year of the premium data and 
the BHP plan year. We are proposing to define this as the premium trend 
factor in the BHP payment methodology. This factor would approximate 
the change in health care costs per enrollee, which would include, but 
not be limited to, changes in the price of health care services and 
changes in the utilization of health care services. This would provide 
an estimate of the adjusted monthly premium for the applicable second 
lowest cost silver plan that would be more accurate and reflective of 
health care costs in the BHP program year, which would be the year 
following issuance of the final federal payment notice. In addition, we 
believe that it would be appropriate to adjust the trend factor for the 
estimated impact of changes to the transitional reinsurance program on 
the average QHP premium.
    For the trend factor we propose to use the annual growth rate in 
private health insurance expenditures per enrollee from the National 
Health Expenditure projections, developed by the Office of the Actuary 
in CMS (citation, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2012.pdf).
    We propose to also include an adjustment for changes in the 
transitional reinsurance program. We propose that this adjustment would 
be developed from analysis by CMS' Center for Consumer Information and 
Insurance Oversight (CCIIO).
    States may want to consider that the increase in premiums for QHPs 
from 2015 to 2016 may differ from the premium trend factor developed 
for the BHP funding methodology for several reasons. In particular, 
states may want to consider that the second lowest cost silver plan for 
2015 may not be the same as the second lowest cost silver plan in 2016. 
This may lead to the premium trend factor being greater than or less 
than the actual change in the premium of the second lowest cost silver 
plan in 2015 compared to the premium of the second lowest cost silver 
plan in 2016.

G. State Option To Include Retrospective State-Specific Health Risk 
Adjustment in Certified Methodology

    To determine whether the potential difference in health status 
between BHP enrollees and consumers in the Exchange would affect the 
PTC, CSRs, risk adjustment and reinsurance payments that would have 
otherwise been made had BHP enrollees been enrolled in coverage on the 
Exchange, we propose to provide states implementing the BHP the option 
to propose and to implement, as part of the certified methodology, a 
retrospective adjustment to the federal BHP payments to reflect the 
actual value that would be assigned to the population health factor (or 
risk adjustment) based on data accumulated during program year 2016 for 
each rate cell.
    We acknowledge that there is uncertainty with respect to this 
factor due to the lack of experience of QHPs on the Exchange and other 
payments related to the Exchange, which is why, absent a state 
election, we propose to use a value for the population health factor to 
determine a prospective payment rate which assumes no difference in the 
health status of BHP enrollees and QHP enrollees. There is considerable 
uncertainty regarding whether the BHP enrollees will pose a greater 
risk or a lesser risk compared to the QHP enrollees, how to best 
measure such risk, and the potential effect such risk would have had on 
PTC, CSRs, risk adjustment and reinsurance payments that would have 
otherwise been made had BHP enrollees been enrolled in coverage on the 
Exchange. To the extent, however, that a state would develop an 
approved protocol to collect data and effectively measure the relative 
risk and the effect on federal payments, we propose to permit a 
retrospective adjustment that would measure the actual difference in 
risk between the two populations to be incorporated into the certified 
BHP payment methodology and used to adjust payments in the previous 
year.
    For a state electing the option to implement a retrospective 
population health status adjustment, we propose requiring the state to 
submit a proposed protocol to CMS, which would be subject to approval 
by CMS and would be required to be certified by the Chief Actuary of 
CMS, in consultation with the Office of Tax Analysis, as part of the 
BHP payment methodology. CMS described the protocol for the population 
health status adjustment in guidance in Considerations for Health

[[Page 63374]]

Risk Adjustment in the Basic Health Program in Program Year 2015 
(http://www.medicaid.gov/Basic-Health-Program/Downloads/Risk-Adjustment-and-BHP-White-Paper.pdf). We propose requiring a state to 
submit its proposed protocol by August 1, 2015 for CMS approval. This 
submission would also include descriptions of how the state would 
collect the necessary data to determine the adjustment, including any 
contracting contingences that may be in place with participating 
standard health plan issuers. We would provide technical assistance to 
states as they develop their protocols. In order to implement the 
population health status, we propose that CMS must approve the state's 
protocol no later than December 31, 2015. Finally, we propose that the 
state be required to complete the population health status adjustment 
at the end of 2016 based on the approved protocol. After the end of the 
2016 program year, and once data is made available, we propose that CMS 
would review the state's findings, consistent with the approved 
protocol, and make any necessary adjustments to the state's federal BHP 
payment amount. If we determine that the federal BHP payments were less 
than they would have been using the final adjustment factor, we would 
apply the difference to the state's quarterly BHP trust fund deposit. 
If we determine that the federal BHP payments were more than they would 
have been using the final reconciled factor, we would subtract the 
difference from the next quarterly BHP payment to the state.

H. Example Application of the BHP Funding Methodology

    In the 2015 proposed payment methodology, we included an example of 
how the BHP funding methodology would be applied (Proposed Basic Health 
Program 2015 Funding Methodology, (78 FR 77399), published in the 
Federal Register on December 23, 2013). For those interested in this 
example, we would refer to the 2015 proposed payment methodology and 
note the following changes since that time.
    In the final BHP payment methodology, we provided the option for 
states to elect to use the 2015 premiums to calculate the BHP payment 
rates instead of the 2014 premiums multiplied by the premium trend 
factor. The example in the previous proposed payment methodology used 
the 2014 premiums multiplied by the premium trend factor only.
    In addition, we provided the option for the state to develop a risk 
adjustment protocol to revise the population health factor in the final 
payment methodology. The example in the previous proposed payment 
methodology did not assume any adjustment to the population health 
factor.
    Furthermore, we modified the age ranges used to develop the rate 
cells after the proposed payment methodology was published. The age 
range for persons ages 21-44 was divided into age ranges of 21-34 and 
35-44.
    Lastly, as we noted in the responses to comments in the final 
payment methodology, there was an error in the example in the previous 
proposed payment methodology. The maximum percentage of income that a 
household would be required to pay for QHP premiums for households with 
incomes between 133 percent and 150 percent of the federal poverty 
level (FPL) was incorrect in the example; the correct percentages range 
from 3.00 to 4.00 percent, not from 2.00 to 3.00 percent as shown in 
Table 2.

III. Collection of Information Requirements [If Applicable]

    This proposed methodology is unchanged from the 2015 final 
methodology that published on March 12, 2014 (79 FR 13887). The 2016 
proposed methodology would not impose any new or revised reporting, 
recordkeeping, or third-party disclosure requirements and, therefore, 
does not require additional OMB review under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). The 
methodology's information collection requirements and burden estimates 
are approved by OMB under control number 0938-1218 (CMS-10510).
    Consistent with the Basic Health Program's proposed and final rules 
(78 FR 59122 and 79 FR 14112, respectively) we continue to estimate 
less than 10 annual respondents for completing the Blueprint. 
Consequently, the Blueprint is exempt from formal OMB review and 
approval under 5 CFR 1320.3(c).
    Finally, this action would not impose any additional reporting, 
recordkeeping, or third-party disclosure requirements on qualified 
health plans or on states operating State Based Exchanges.

IV. Response to Comments

    Because of the large number of public comments we normally receive 
on Federal Register documents, we are not able to acknowledge or 
respond to them individually. We will consider all comments we receive 
by the date and time specified in the DATES section of this preamble, 
and, when we proceed with a subsequent document, we will respond to the 
comments in the preamble to that document.

V. Regulatory Impact Statement

A. Overall Impact

    We have examined the impacts of this rule as required by Executive 
Order 12866 on Regulatory Planning and Review (September 30, 1993), 
Executive Order 13563 on Improving Regulation and Regulatory Review 
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 
1980, Pub. L. 96-354), section 1102(b) of the Act, section 202 of the 
Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4, March 22, 1995) 
(UMRA), Executive Order 13132 on Federalism (August 4, 1999) and the 
Congressional Review Act (5 U.S.C. 804(2)).
    Executive Orders 12866 and 13563 direct agencies to assess all 
costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). Section 
3(f) of Executive Order 12866 defines a ``significant regulatory 
action'' as an action that is likely to result in a rule: (1) Having an 
annual effect on the economy of $100 million or more in any 1 year, or 
adversely and materially affecting a sector of the economy, 
productivity, competition, jobs, the environment, public health or 
safety, or state, local or tribal governments or communities (also 
referred to as ``economically significant''); (2) creating a serious 
inconsistency or otherwise interfering with an action taken or planned 
by another agency; (3) materially altering the budgetary impacts of 
entitlement grants, user fees, or loan programs or the rights and 
obligations of recipients thereof; or (4) raising novel legal or policy 
issues arising out of legal mandates, the President's priorities, or 
the principles set forth in the Executive Order.
    A regulatory impact analysis (RIA) must be prepared for major rules 
with economically significant effects ($100 million or more in any 1 
year). As noted in the BHP final rule, BHP provides states the 
flexibility to establish an alternative coverage program for low-income 
individuals who would otherwise be eligible to purchase coverage 
through the Exchange. We are uncertain as to whether the effects of the 
final rulemaking, and subsequently, this methodology, will be 
``economically

[[Page 63375]]

significant'' as measured by the $100 million threshold, and hence not 
a major rule under the Congressional Review Act. The impact may depend 
on several factors, including the number of and which particular states 
choose to implement or continue BHP in 2016, the level of QHP premiums 
in 2015 and 2016, the number of enrollees in BHP, and the other 
coverage options for persons who would be eligible for BHP. In 
particular, while we generally expect that many enrollees would have 
otherwise been enrolled in a QHP through the Exchange, some persons may 
have been eligible for Medicaid under a waiver or a state health 
coverage program. For those who would have enrolled in a QHP and thus 
would have received PTCs or CSRs, the federal expenditures for BHP 
would be expected to be more than offset by a reduction in federal 
expenditures for PTCs and CSRs. For those who would have been enrolled 
in Medicaid, there would likely be a smaller offset in federal 
expenditures (to account for the federal share of Medicaid 
expenditures), and for those who would have been covered in non-federal 
programs or would have been uninsured, there likely would be an 
increase in federal expenditures. In accordance with the provisions of 
Executive Order 12866, this methodology was reviewed by the Office of 
Management and Budget.
1. Need for the Methodology
    Section 1331 of the Affordable Care Act (codified at 42 U.S.C. 
18051) requires the Secretary to establish a BHP, and section (d)(1) 
specifically provides that if the Secretary finds that a state ``meets 
the requirements of the program established under section (a) [of 
section 1331 of the Affordable Care Act], the Secretary shall transfer 
to the State'' federal BHP payments described in section (d)(3). This 
proposed methodology provides for the funding methodology to determine 
the federal BHP payment amounts required to implement these provisions 
in program year 2016.
2. Alternative Approaches
    Many of the factors proposed in this methodology are specified in 
statute; therefore, we are limited in the alternative approaches we 
could consider. One area in which we had a choice was in selecting the 
data sources used to determine the factors included in the proposed 
methodology. Except for state-specific reference premiums and 
enrollment data, we propose using national rather than state-specific 
data. This is due to the lack of currently available state-specific 
data needed to develop the majority of the factors included in the 
proposed methodology. We believe the national data will produce 
sufficiently accurate determinations of payment rates. In addition, we 
believe that this approach will be less burdensome on states. To 
reference premiums and enrollment data, we propose using state-specific 
data rather than national data as we believe state-specific data will 
produce more accurate determinations than national averages.
    In addition, we considered whether or not to provide states the 
option to develop a protocol for a retrospective adjustment to the 
population health factor in 2016 as we did in the 2015 payment 
methodology. We believe that providing this option again in 2016 is 
appropriate and likely to improve the accuracy of the final payments.
    We also considered whether or not to require the use of 2015 or 
2016 QHP premiums to develop the 2016 federal BHP payment rates. We 
believe that the payment rates can still be developed accurately using 
either the 2015 or 2016 QHP premiums and that it is appropriate to 
provide the states the option, given the interests and specific 
considerations each state may have in operating the BHP.
3. Transfers
    The provisions of this methodology are designed to determine the 
amount of funds that will be transferred to states offering coverage 
through a BHP rather than to individuals eligible for premium and cost-
sharing reductions for coverage purchased on the Exchange. We are 
uncertain what the total federal BHP payment amounts to states will be 
as these amounts will vary from state to state due to the varying 
nature of state composition. For example, total federal BHP payment 
amounts may be greater in more populous states simply by virtue of the 
fact that they have a larger BHP-eligible population and total payment 
amounts are based on actual enrollment. Alternatively, total federal 
BHP payment amounts may be lower in states with a younger BHP-eligible 
population as the reference premium used to calculate the federal BHP 
payment will be lower relative to older BHP enrollees. While state 
composition will cause total federal BHP payment amounts to vary from 
state to state, we believe that the proposed methodology accounts for 
these variations to ensure accurate BHP payment transfers are made to 
each state.

B. Unfunded Mandates Reform Act

    Section 202 of the UMRA requires that agencies assess anticipated 
costs and benefits before issuing any rule whose mandates require 
spending in any 1 year of $100 million in 1995 dollars, updated 
annually for inflation, by state, local, or tribal governments, in the 
aggregate, or by the private sector. In 2014, that threshold is 
approximately $141 million. States have the option, but are not 
required, to establish a BHP. Further, the proposed methodology would 
establish federal payment rates without requiring states to provide the 
Secretary with any data not already required by other provisions of the 
Affordable Care Act or its implementing regulations. Thus, this 
proposed payment notice does not mandate expenditures by state 
governments, local governments, or tribal governments.

C. Regulatory Flexibility Act

    The Regulatory Flexibility Act (5 U.S.C. 601 et seq.) (RFA) 
requires agencies to prepare an initial regulatory flexibility analysis 
to describe the impact of the proposed rule on small entities, unless 
the head of the agency can certify that the rule will not have a 
significant economic impact on a substantial number of small entities. 
The Act generally defines a ``small entity'' as (1) a proprietary firm 
meeting the size standards of the Small Business Administration (SBA); 
(2) a not-for-profit organization that is not dominant in its field; or 
(3) a small government jurisdiction with a population of less than 
50,000. Individuals and states are not included in the definition of a 
small entity. Few of the entities that meet the definition of a small 
entity as that term is used in the RFA would be impacted directly by 
this proposed methodology.
    Because this proposed methodology is focused on the proposed 
funding methodology that will be used to determine federal BHP payment 
rates, it does not contain provisions that would have a significant 
direct impact on hospitals, and other health care providers that are 
designated as small entities under the RFA. We cannot determine whether 
this proposed methodology would have a significant economic impact on a 
substantial number of small entities, and we request public comment on 
this issue.
    Section 1102(b) of the Act requires us to prepare a regulatory 
impact analysis if a proposed methodology may have a significant 
economic impact on the operations of a substantial number of small 
rural hospitals. For purposes of section 1102(b) of the Act, we define 
a small rural hospital as a hospital that is located outside of a 
metropolitan statistical area and has fewer than 100 beds. As indicated 
in the preceding

[[Page 63376]]

discussion, there may be indirect positive effects from reductions in 
uncompensated care. Again, we cannot determine whether this proposed 
methodology would have a significant economic impact on a substantial 
number of small rural hospitals, and we request public comment on this 
issue.

D. Federalism

    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct effects on states, preempts 
state law, or otherwise has federalism implications. The BHP is 
entirely optional for states, and if implemented in a state, provides 
access to a pool of funding that would not otherwise be available to 
the state.

    Dated: September 19, 2014.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
    Approved: October 19, 2014.
Sylvia Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2014-25257 Filed 10-21-14; 4:15 pm]
BILLING CODE 4120-01-P