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Electronic Code of Federal Regulations

e-CFR data is current as of January 22, 2020

Title 45Subtitle ASubchapter BPart 158


TITLE 45—Public Welfare

Subtitle A—DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER B—REQUIREMENTS RELATING TO HEALTH CARE ACCESS

PART 158—ISSUER USE OF PREMIUM REVENUE: REPORTING AND REBATE REQUIREMENTS

rule
§158.101
Basis and scope.
§158.102
Applicability.
§158.103
Definitions.

Subpart A—DISCLOSURE AND REPORTING

§158.110
Reporting requirements related to premiums and expenditures.
§158.120
Aggregate reporting.
§158.121
Newer experience.
§158.130
Premium revenue.
§158.140
Reimbursement for clinical services provided to enrollees.
§158.150
Activities that improve health care quality.
§158.151
Expenditures related to Health Information Technology and meaningful use requirements.
§158.160
Other non-claims costs.
§158.161
Reporting of Federal and State licensing and regulatory fees.
§158.162
Reporting of Federal and State taxes.
§158.170
Allocation of expenses.
rule

Subpart B—CALCULATING AND PROVIDING THE REBATE

§158.210
Minimum medical loss ratio.
§158.211
Requirement in States with a higher medical loss ratio.
§158.220
Aggregation of data in calculating an issuer's medical loss ratio.
§158.221
Formula for calculating an issuer's medical loss ratio.
§158.230
Credibility adjustment.
§158.231
Life-years used to determine credible experience.
§158.232
Calculating the credibility adjustment.
§158.240
Rebating premium if the applicable medical loss ratio standard is not met.
§158.241
Form of rebate.
§158.242
Recipients of rebates.
§158.243
De minimis rebates.
§158.244
Unclaimed rebates.
§158.250
Notice of rebates.
§158.251
Notice of MLR information.
§158.260
Reporting of rebates.
§158.270
Effect of rebate payments on solvency.
rule

Subpart C—POTENTIAL ADJUSTMENT TO THE MLR FOR A STATE'S INDIVIDUAL MARKET

§158.301
Standard for adjustment to the medical loss ratio.
§158.310
Who may request adjustment to the medical loss ratio.
§158.311
Duration of adjustment to the medical loss ratio.
§158.320
Information supporting a request for adjustment to the medical loss ratio.
§158.321
Information regarding the State's individual health insurance market.
§158.322
Proposal for adjusted medical loss ratio.
§158.323
State contact information.
§158.330
Criteria for assessing request for adjustment to the medical loss ratio.
§158.340
Process for submitting request for adjustment to the medical loss ratio.
§158.341
Treatment as a public document.
§158.342
Invitation for public comments.
§158.343
Optional State hearing.
§158.344
Secretary's discretion to hold a hearing.
§158.345
Determination on a State's request for adjustment to the medical loss ratio.
§158.346
Request for reconsideration.
§158.350
Subsequent requests for adjustment to the medical loss ratio.
rule

Subpart D—HHS ENFORCEMENT

§158.401
HHS enforcement.
§158.402
Audits.
§158.403
Circumstances in which a State is conducting audits of issuers.
rule

Subpart E—ADDITIONAL REQUIREMENTS ON ISSUERS

§158.501
Access to facilities and records.
§158.502
Maintenance of records.
rule

Subpart F—FEDERAL CIVIL PENALTIES

§158.601
General rule regarding the imposition of civil penalties.
§158.602
Basis for imposing civil penalties.
§158.603
Notice to responsible entities.
§158.604
Request for extension.
§158.605
Responses to allegations of noncompliance.
§158.606
Amount of penalty—general.
§158.607
Factors HHS uses to determine the amount of penalty.
§158.608
Determining the amount of the penalty—mitigating circumstances.
§158.609
Determining the amount of penalty—aggravating circumstances.
§158.610
Determining the amount of penalty—other matters as justice may require.
§158.611
Settlement authority.
§158.612
Limitations on penalties.
§158.613
Notice of proposed penalty.
§158.614
Appeal of proposed penalty.
§158.615
Failure to request a hearing.

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