State-Specific Threshold Proposals

The HHS Notice of Benefit and Payment Parameters for 2019 Final Rule (2019 Final Payment Notice) provides for a 15 percent Federal default threshold for the reasonableness review of rate increases. As specified in 45 C.F.R. § 154.200(a)(2), CMS will only require a proposal when a State is requesting a higher threshold. States that impose stricter standards will communicate those standards to their issuers as they currently do with many other aspects of State-specific requirements. Information from States that request a threshold higher than 15 percent will be posted here.

On April 9, 2018, CMS released guidance to inform States of the process for submitting proposals for State-specific thresholds for single risk pool rate filings submitted by issuers for plan or policy years beginning on or after January 1, 2019.  That guidance is available here.

States wishing to propose a State-specific threshold to be used for a twelve month period beginning January 1 of any year should submit proposals to CMS no later than August of the preceding year. States are encouraged to submit proposals earlier than the deadline, if possible.

Proposals may be submitted by email to: ratereview@cms.hhs.gov, or by regular mail at:

Center for Medicare and Medicaid Services
Center for Consumer Information and Insurance Oversight
7500 Security Blvd.
Mail stop –WB-22-75
Woodlawn, MD 21244
ATTN:  State-specific Threshold Review