How to Complete the Business Rules Template
Issuers seeking to offer qualified health plans, or QHPs,
including stand-alone dental plans, or SADPs, on the Federally-facilitated Exchange must submit a
completed QHP Application per CMS guidelines.
As part of the QHP certification process,
issuers are asked to fill out several templates with issuer- and plan-level data.
These templates, along with any supporting documentation submitted, comprise an issuer’s QHP Application.
Among these templates is the Business Rules Template.
The Business Rules Template defines the rules used to calculate rates and determine whether consumers
are eligible for coverage under each plan.
To download the Business Rules Template
and applicable instructions, visit the Business Rules webpage of the QHP certification website.
This webpage contains more information about the Business Rules section of the QHP Application,
including tips and additional resources.
Before filling out the Business Rules Template,
download and read the instructions from the Application Resources section.
Once you’re ready to complete the Business Rules Template, download the template from
the Application Resources section, open the template, and enable macros.
Within the Business Rules Template, there are several data fields.
Note that dual-product issuers should use the same template for both their QHPs and SADPs.
When filling out templates in the QHP Application, start in the top left corner,
and fill out fields moving down and to the right until all required fields are completed.
Now let’s walk through filling out the Business Rules Template with sample data.
Before you begin, look through the data elements required to ensure
you have the necessary plan information to successfully complete this template.
To begin, enter the 5-digit HIOS Issuer ID you received when you registered in
the Health Insurance Oversight System, or HIOS, and the type of plans you are offering—medical,
dental, or both. The first row under the
“Product ID” column is where issuers establish the base set of business rules for their plans.
In this row, the product ID and plan ID, the standard component, are grayed out. The rules
established in this row will be applied to all products and plans associated with the issuer ID,
except when specified in subsequent rows. These rules are known as issuer-level business rules.
Issuers submitting in HIOS and the System for Electronic Rates & Forms Filing, or SERFF,
are only allowed one set of issuer-level business rules. Note that issuers submitting in SERFF must
submit one Business Rules Template across all SERFF binders; this template must contain all
business rules associated with all plan IDs being submitted for QHP certification.
This requirement prevents the data from an issuer’s submitted business rules from being overwritten
at the issuer, product, and plan levels. The remaining fields in the first row are
required. For the issuer-level business rule, row 10, the value for “Medical or Dental Rule?” will
default to "Medical" if the issuer is entering only medical plans, or both medical and dental plans,
into the template. It will default to "Dental" if the issuer is offering only dental plans.
The next data element asks you to indicate the maximum number
of rated underage dependents on this policy.
Select “1” to indicate that, regardless of the number of children on a plan,
only the oldest child’s premium is added to the adults’ premiums to calculate the family premium.
Select “2” to use the two oldest children’s premiums.
Select “3” to use the three oldest children’s premiums.
For medical plans, a maximum of three children’s premiums can be used to calculate family premiums.
Dental plans are not subject to this limit, and have the option
to rate for more than 3 children by entering a value of “Not Applicable.”
In column E, indicate whether there is a maximum age for a dependent. If you answer “Yes,” enter
the maximum dependent age in the dialogue box that appears and select “OK.”
Issuers are required to enter a value greater than 24 for QHPs, and a value greater than 17 for SADPs.
Note that the value entered is inclusive, so that a value of 25 includes age 25, up to age 26.
The next column asks how age is determined for rating and eligibility purposes.
For all medical QHP products and plans, select “Age on effective date.”
Issuers may use the other values from the dropdown for SADP products and plans.
In the next column, indicate how tobacco status is determined for subscribers and dependents.
Selecting “Not Applicable” indicates the plan charges the same rate to all subscribers,
regardless of tobacco usage. If your plan rates for tobacco,
select “Applicable - [x] months,” and enter the number of months
a subscriber or dependent must be tobacco-free in order to be considered a non-user. Select OK.
Note that medical products and plans cannot have a value greater than six months in this field.
The next column asks you to indicate which relationships between the primary subscriber
and dependents are allowed, and whether dependents are required to live in the same household
as the primary subscriber. Choose “Click to Select,” and place a checkmark next to each
dependent relationship allowed to be enrolled on the same policy as the primary subscriber.
For each selected dependent relationship, select “Yes” or “No” to indicate whether that dependent
is required to live in the same household as the primary subscriber.
Note that for all medical products and plans, you must select “No” for any child dependent relationship that you elect to
cover, including Child, Foster Child, and Stepson or Stepdaughter.
Once you’ve finished, click “OK.”
Once you’ve completed entering the base set of issuer business rules in this row, enter any
exceptions or differing product- or plan-level business rules in subsequent rows, as needed.
Include the 10-character HIOS-generated product ID that identifies the product that
will be associated with the rules defined in the corresponding row.
Enter the 14-character plan ID to further differentiate plan-level business rules.
If any value is left blank in these subsequent rows, the corresponding value for the issuer-level rule
will apply to the product- or plan-level rule. Continue adding plan- and product-level business
rules as appropriate, until all business rules for this issuer have been defined.
Now, let’s validate and finalize the template.
Once you have completed the template,
click the “Validate” button in the top left corner of the worksheet.
Any data issues in your template that need to be resolved will be displayed; correct these and
click the Validate button again. Continue this process until all errors have been resolved.
Once the template is valid, click the “Finalize” button to create an
XML that will be automatically saved in the same folder as the template.
The XML extract is the file you will submit as part of your QHP Application.
If you have questions regarding your QHP Application, please
contact the Marketplace Service Desk at CMS_FEPS@cms.hhs.gov or 855-CMS-1515.
For more information about the QHP certification process, visit www.qhpcertification.cms.gov.