(a)In establishing rates for health insurance coverage offered in the individual market, the rate may vary with respect to the particular plan or coverage involved only by determining the following:
(1)Whether the plan or coverage covers an individual or family.
(2)Rating area, as established in accordance with subsection (d) of this section.
(3)Age, except that the rate may not vary by more than 3 to 1 for like individuals of different age who are age 21 and older and that the variation in rate must be actuarially justified for individuals under age 21, consistent with the uniform age rating curve under subsection (e) of this section. For purposes of identifying the appropriate age adjustment under this paragraph (a)(3) and the age band under subsection (e) of this section applicab
Free access — add to your briefcase to read the full text and ask questions with AI
(a) In establishing rates for health insurance coverage offered in the individual market, the rate may vary with respect to the particular plan or coverage involved only by determining the following:
(1) Whether the plan or coverage covers an individual or family.
(2) Rating area, as established in accordance with subsection (d) of this section.
(3) Age, except that the rate may not vary by more than 3 to 1 for like individuals of different age who are age 21 and older and that the variation in rate must be actuarially justified for individuals under age 21, consistent with the uniform age rating curve under subsection (e) of this section. For purposes of identifying the appropriate age adjustment under this paragraph (a)(3) and the age band under subsection (e) of this section applicable to a specific enrollee, the enrollee’s age as of the date of policy issuance or renewal must be used.
(4) Subject to § 3611 of this title, tobacco use, except that such rate may not vary by more than 1.5 to 1 and may only be applied with respect to individuals who may legally use tobacco under federal and state law. For purposes of this paragraph (a)(4), tobacco use means use of tobacco on average 4 or more times per week within no longer than the past 6 months. This includes all tobacco products, except that tobacco use does not include religious or ceremonial use of tobacco. Further, tobacco use must be defined in terms of when a tobacco product was last used.
(b) The rate established under this section must not vary with respect to the particular plan or coverage involved by any other factor not described in subsection (a) of this section.
(c) A health insurer must consider the claims experience of all enrollees in all health plans, other than grandfathered health plans, offered by such insurer in individual market in this State, including those enrollees who do not enroll in such plans through the state health exchange, to be members of a single risk pool. A health insurer must charge the same premium rate without regard to whether the plan is offered through the state health exchange or whether the plan is offered directly from the health insurer or through an agent.
(d) In establishing rates, all health insurers offering health plans in the individual market shall use a single rating area that applies to the entire State.
(e) The following uniform age bands apply for rating purposes under paragraph (a)(3) of this section:
(1)Child age bands. —
a. A single age band for individuals age 0 through 14.
b. One-year age bands for individuals age 15 through 20.
(2)Adult age bands. —
One-year age bands for individuals age 21 through 63.
(3)Older adult age bands. —
A single age band for individuals age 64 and older.
(f)Application of variations based on age or tobacco use. —
With respect to family coverage under health insurance coverage, the rating variations permitted under paragraphs (a)(3) and (a)(4) of this section must be applied based on the portion of the premium attributable to each family member covered under the coverage.
(1) The total premium for family coverage must be determined by summing the premiums for each individual family member. With respect to family members under age 21, the premiums for no more than the 3 oldest covered children must be taken into account in determining the total family premium.
(2) If the State does not permit any rating variation for the factors described in paragraphs (a)(3) and (a)(4) of this section, as determined by the Insurance Commissioner by regulation, the State may require that premiums for family coverage be determined by using uniform family tiers and the corresponding multipliers established by the State. If the State does not establish uniform family tiers and the corresponding multipliers, the per-member-rating methodology under paragraph (f)(1) of this section applies in this State.
(g) The Commissioner may adopt regulations, in accordance with the Administrative Procedures Act (Chapter 101 of Title 29), that are consistent with Chapter 25 of this title and set forth more specifically the rating standards and requirements for health insurers operating within this State.