16 Del. Admin. Code § 5001-4.0

Current through Register Vol. 28, No. 7, January 1, 2025

Section 5001-4.0 - Information Reporting

4.1 The State entered into an intergovernmental agreement with the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS), to calculate reinsurance payments to issuers participating in the State of Delaware's reinsurance program under Delaware's State Innovation Waiver under section 1332 of the Patient Protection and Affordable Care Act. CMS will identify paid claims eligible for reimbursement under the reinsurance program from data submitted to "EDGE Servers."

4.2 Carriers must sign an attestation that they meet the submission and data requirements of the State Reinsurance Program through their participation in CMS EDGE Server.

4.3 A reinsurance eligible issuer must submit one interim report due on March 31st after the benefit year, containing de-identified data from the prior benefit year with claims paid by February 28th or February 29th, and an estimate of claims payments still outstanding. This report will be used to aid the Executive Director in setting parameters for future program years; the EDGE Server, and not this report, shall be used to calculate the paid claims eligible for reimbursement under the reinsurance program. The report shall be issued using a secure method of transmission approved by the Executive Director. The Executive Director may, in his or her discretion, waive the interim report.

4.4 The interim report must contain the following data elements for the individual ACA plan:

4.4.1 De-identified Member ID;

4.4.2 Benefit Year Member Months;

4.4.3 Benefit Year Incurred Claims (paid through February 28th or February 29th of the current calendar year); and

4.4.4 Estimate of prior Benefit Year claim payments outstanding, e.g., to be paid after February 28th or February 29th of the current calendar year.

4.5 DHCC shall annually receive from the Department of Insurance the actual Second Lowest Cost Silver Plan premium under the Affordable Care Act 1332 waiver, 45 U.S.C. § 18052, and an estimate of the premium as it would have been without the waiver.

4.6 If the State's participation in the CMS EDGE Server were to be discontinued, as a condition of receiving reinsurance payments from the program, a reinsurance eligible issuer would provide the following information to the program in the form and manner prescribed by the Executive Director:

4.6.1 The name and company code assigned to the reinsurance eligible issuer by the National Association of Insurance Commissioners;

4.6.2 The identification number assigned to the reinsurance eligible issuer by the DHCC;

4.6.3 The total amount of the reinsurance eligible issuer's reinsurance eligible claims for the benefit year;

4.6.4 The portion of the reinsurance eligible issuer's total reinsurance eligible claims for the benefit year that fall between the attachment point and reinsurance cap;

4.6.5 A summary data file containing de-identified information for each reinsurance eligible individual with claims for which reinsurance payments are being requested:

4.6.5.1 The start and end dates of coverage for the reinsurance eligible individual;

4.6.5.2 The DHCC plan identification number for the reinsurance eligible health benefit plan in which the reinsurance eligible individual was enrolled;

4.6.5.3 The total amount of reinsurance eligible claims for the reinsurance eligible individual for the benefit year; and

4.6.5.4 The total amount of reinsurance eligible claims for the reinsurance eligible individual for the benefit year that fall between the attachment point and reinsurance cap.

4.6.6 If requested by the Executive Director de-identified claims file extracted from the reinsurance eligible issuer's claims processing system that includes the issuer's complete record of all reinsurance eligible claims for the benefit year, in accordance with applicable state and federal confidentiality laws;

4.6.7 An attestation signed by an executive officer of the reinsurance eligible issuer stating that the information is accurate as of the date of submission; and

4.6.8 Any other information requested by the Executive Director that he or she deems necessary to administer the program, in accordance with applicable state and federal confidentiality laws.

16 Del. Admin. Code § 5001-4.0

24 DE Reg. 1009( 5/1/2021) (final)