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Common Rate Filing Questions (revised July 2018)
Individual (IHC) and Small Employer (SEH)

Q1. What are the due dates for IHC and SEH rate filings? NEW

A. IHC and SEH rate filings are due to the Department as follows:

  • 2019 Rate filing deadline - Due to CMS’ delayed release of the Summary Report on Permanent Risk Adjustment Transfers for the 2017 Benefit Year and its announcement of the suspension of Risk Adjustment payments, the deadline to file rates for 2019 has been extended from July 11, 2018 to July 18, 2018. The individual plan rate filing shall not take into account the potential impact of a reinsurance program. The individual and small employer plan filings shall assume risk adjustment payments continue for 2019. The carriers’ actuarial memorandum must discuss the potential impact on rates if risk adjustment payments were to be discontinued for 2019. Both the individual and small employer plan filings must be complete with all elements necessary for transfer to HIOS on July 25, 2018.
  • Additional Individual Plan Rate Submission Taking into Account a Reinsurance Program in 2019 - On or before July 18, 2018, carriers are also to submit 2019 annual rates that shall take into account a reinsurance program using the following parameters: 60% coinsurance rate; $40,000 attachment point, and $215,000 reinsurance cap. Based on the actuarial consultant analysis of claims data submitted pursuant to Department Order No. A18-102, it is expected that these reinsurance parameters will reduce carrier costs to support at least a 15% reduction in premiums in the individual market. Accordingly, a rate submission that is not at least 15% below the rates filed for plans with no reinsurance must include detailed actuarial support to justify the lesser rate decrease. The filing will also assume that risk adjustment payments continue for 2019.

Quarterly SEH rate filings are due 105 days prior to the effective date which means:

  • 2Q2019 rate filings effective 04/01/2019 are due by 12/17/2018.
  • 3Q2019 rate filings effective 07/01/2019 are due by 03/18/2019.
  • 4Q2019 rate filings effective 10/01/2019 are due by 06/18/2019.

Q2. Are SEH carriers permitted to introduce new plans mid-year for non-SHOP business? 

A. Yes. New SEH plans may be introduced mid-year within the following parameters:

  • Plans may only be offered for non-SHOP business;
  • Rate development for these plans must be based on the single risk pool;
  • Benefit Summary Tables for these plans must be included in the rate filings;
  • Network(s) for these new plans must have been filed with, and approved by the Department; evidence of the approval must be included in the rate filing; and
  • Plans must be offered as guaranteed issue and participation and contribution requirements cannot be applied to any small employer applying for such new plans for the balance of the calendar year. 

Q3. What specific data elements are to be included in the IHC and SEH rate filings?

A. Rate filings must contain the following elements:

  • NEW NJ State TemplateNo longer required for rate filings effective 01/01/2019 and later.
    : New Jersey Benefit Summary Tables continue to be required.
  • NEW HIOS Tracking # - must be entered in the Filing Description.
  • Part I Unified Rate Review Template (URRT) (45 CFR 154.215) – Excel.xls version only
  • Part II Written Description Justification (45 CFR 154.215) – A consumer-friendly written description justifying, and listing all rate increases at or above the threshold. 
    • For 2019, New Jersey continues to apply a 10% threshold for filing rate increase justifications with CMS.
    • For SHOP, the Annual Part II must specifically address, and list, all rate increases at or above the 10% threshold for the year, by quarter.
  • Part III Actuarial Memorandum (AM) (45 CFR 154.215) – A separate NJ state-specific actuarial memorandum is not required and should not be submitted.
  • The Part III AM must contain the additional actuarial memorandum data elements required by New Jersey regulation at: N.J.A.C. 11:20-6.3 (IHC) and N.J.A.C. 11:21-9.3 (SEH) and as listed on the Rate Filing Checklists.
    • NEW The Part III AM should include an attribution analysis section to explain (both quantitatively and qualitatively) the impact of the key cost drivers. The actuarial analysis will help DOBI evaluate the reasonableness of the rate increases proposed for 2019.  The actuarial analysis must take the following into consideration:

      • Impact of rate increase related to the elimination of the Individual Mandate.
      • Cost Sharing Reductions (CSR) Adjustments – For 2019, carriers offering individual plans through the Federally-Facilitated Marketplace (FFM) are directed to submit rates that account for the lack of CSR funding by loading that cost into the premiums for silver metal level plans offered through the Marketplace only.  
      • Impact of recently enacted laws specifically including P.L. 2017, c 28 (Substance use disorder). 
      • Claims experience in 2017 and 1Q 2018 (including anticipated Risk Adjustment payments).
      • Medical trend.
      • Prescription Drug trend.
      • Other important factors (e.g., competitive landscape, surplus position, plan designs, and OON issues).
      • Prior year Medical Loss Ratio (MLR) estimate.
  • Actuarial Value (AV) Calculator “Screen Shots” – one for each plan in the rate filing.  For IHC carriers, this includes the three CSR variations (73%, 87%, and 94%) for Silver plans offered through the Marketplace. 
  • A Table of Contents and a Rate Manual – Word.doc only
    • Table of Contents shall include the date of the filing, a list of documents and page numbers.
    • A Rate Manual.
    • A 3-part footer which contains: (1) SERFF# and document name, (2) page #, and (3) date created or revised.
  • Carrier Specific Rate Chart – updated to reflect carrier rate information as of the current effective date. The Rate Chart must include rates for each carrier and must be submitted, via SERFF, as an Excel.xls file.  Rates for affiliated carriers must be included in the separate rate filings for the affiliated carriers. 
    • Carriers must not change the content (format, formulas, footnotes or footers) on the standardized Excel spreadsheet created by the Department.  Superscripted footnotes must be added to each relevant plan name.
  • Benefit Summary Tables – complete for each plan to facilitate our review of the benefit information.
    NEW Note: Benefit Summary Tables must be formatted to print on 8.5" x 11" paper and should be submitted in the Plan Management SERFF Binder for review by Ellen DeRosa, Executive Director, IHC and SEH Programs.

    • To capture information associated with out-of-network benefits, use the table specific to plans that have out-of-network benefits.  Similarly, plans that feature tiered network benefits should be described on the appropriate table specific to tiered benefits. 
    • The footnotes include direction to submit evidence regarding network approval as well as documentation to support copays applicable to certain services.  If the same documentation applies to multiple plans it is not necessary to enclose the documentation for each plan. 
    • Final NJDOBI action, with respect to a rate filing, will be pended until the Benefit Summary Tables along with the documentation specified in the footnotes has been received and found to be complete and satisfactory. 
  • NEW Carriers offering small employer plans through the SHOP that update the quarterly rates must submit an updated Federal Rate Table Template through SERFF using the Plan Management module. 
  • Completed Data Change Request Forms – SHOP quarterly rate filing updates, at the time of the SERFF submission, must include the three completed Data Change Request forms required by CMS to submit a revised Federal Rate Table template in the HIOS PM module: Issuer, State, and Worksheet A.

Q4. Does the Department use a checklist when reviewing IHC and SEH rate filings?

A. Yes. These checklists may be found here: IHC Checklist or SEH Checklist.

Q5. Does the Department have required Age Curves which are to be used in the development of IHC and SEH Rates?

A. Yes. The Age Curves may be accessed here:

Q6. How does the Department review rate filings for single risk pool compliance?

A. The carrier is required to provide support that the single risk pools in the New Jersey IHC and SEH markets are established according to the requirement in 45 CFR 156.80. The Department will review such support with respect to the following:

  • Does the claims experience satisfy the requirements in 45 CFR 156.80 (a) – (b)?
  • Does the index rate effective January 1, 2019 satisfy the requirements in 45 CFR 156.80 (d)(1)?
  • Are all permitted plan-level adjustments to the index rate actuarially justified, as required by 45 CFR 156.80 (d)(2)?

With respect to the third bullet above, induced utilization plan-level adjustments will be reviewed by directly comparing the proposed plan-level adjustments to the induced utilization factors found in Table 10 – Cost Sharing Reductions Adjustments in the Proposed HHS Notice of Benefit and Payment Parameters for 2019.

Note: All single risk pool-related support documents must be included within the Part III Actuarial Memorandum tab in SERFF Supporting Documentation.

Q7. How are rate filings to be submitted to the Department?

A. All rate filings must be submitted via SERFF, in compliance with the SERFF Filing rules and requirements, which have been updated and include reference documents and standardized templates, if required.

Q8. How should carriers indicate changes or revisions to data elements in the rate filing?

A.  All elements of the rate filing are required to include a three-part footer showing: (1) SERFF# and document name, (2) page #, and (3) date created or revised. If revisions are made to the filing, the revised text shall be highlighted in turquoise and each page shall be dated clearly and distinctively with the revision date.

Q9. How do carriers revise Excel files (e.g., Rate Chart Template) previously submitted?

A. Corrections to previously submitted files are permitted.  However, carriers should never change the content (format, formulas, footnotes or footers) on a standardized Excel spreadsheet created by the Department.  Changes to the layout of these spreadsheets will delay the review process and require a resubmission.

Q10. When will the review of rate filings be completed by the Department?

A. For annual filings with an effective date of January 1, the Department strives to complete its reviews 45 days prior to the Annual Open Enrollment. For quarterly rate filings, our goal is to finalize the filings 90 days prior to the effective date of the rates. However, the actual timing for the review will vary depending on the completeness and accuracy of the filings.

Q11. When will the IHC and SEH rates be posted to the DOBI web site?

A. The IHC and SEH Annual rate charts and rate calculators will be posted on the Department web site prior to the Annual Open Enrollment period. The SEH Quarterly rate charts and calculators will be posted to the web site prior to the start of each quarter.

Q12. Where can carriers find the rate filing requirements for IHC and SEH?

A. N.J.A.C. 11:20-6 (IHC) and N.J.A.C. 11:21-9 (SEH) contain the rate filing requirements. Bulletin 13-14 addresses amendments to the rate filing rules specifically for IHC and SEH. The requirements apply to all Marketplace, non-Marketplace, SHOP and non-SHOP plan offerings.

HIOS Rate Filing/Rate Review requirements

Q13. Which rate filing documents are required for the different system modules in HIOs?

A.  There are 3 modules in HIOS that are used for the rate filing and rate review processes:

  1. Unified Rate Review (URR) is the repository for rate review documents related to IHC and SEH ACA-compliant Qualified Health Plans (QHPs).
  • Part I URRT and Part III AM (and all referenced exhibits) are required for all rate filings.
  • Part II Justification is required for all rate filings that meet, or exceed, the “subject to review” plan level threshold of 10% and above, on an annualized basis.
  2. Rate Review Justification (RRJ) is the repository for rate review documents related to Transitional Policies.
  • Part I Rate Increase Summary Form, Part II Written Explanation of the Rate Increase and Part III Rate Filing Documentation are required for all rate filings that meet, or exceed, the “subject to review” product level threshold increase of 10% and above, on an annualized basis.
Note: Parts I, II and III must be filed in SERFF for all Transitional Policies and SHP rate filings. 
  3. Plan Management (PM) is the repository for all QHP related information, much of which is displayed on  This includes the annual and quarterly rates reported to HIOS PM, by the carriers, on the Federal Rate Template table.

Q14. When submitting an updated SEH quarterly rate filing to the State, via SERFF, what corresponding forms must be submitted to CMS, via HIOS or via SERFF?

  • HIOS Unified Rate Review (URR) Module – Parts I, II, and III

The URR Instructions require that updated rate submissions for 2Q, 3Q and 4Q, if filed, must contain rates for each of the remaining quarters – regardless of whether the rates shown for the subsequent quarters have changed from what was previously reported for those quarters in the prior filing.

If updated quarterly rates are submitted, the Part I URRT must reflect, in worksheet 2, line 27, the ‘Cumulative Rate Change % (over 12 months prior)’ for each renewing plan, as compared to the rates currently on file for the same period of the previous year.

  • NEW SERFF Plan Management (PM) Module – Federal Rate Table template
    • Rates on the Rate Table template must match the rates in the HIOS Parts I, II and III.
    • The rates that the issuer submits via SERFF must be approved by the Department before being submitted to HIOS.
    • As per the URR Instructions, carriers are prohibited from changing or removing SHOP quarterly rates or worksheets retrospectively.
    • NEW For SHOP quarterly rate changes, a revised Rate Table Template must be submitted through SERFF using the Plan Management module. 

Q15. Are carriers required to confirm that the rate filing information in SERFF is consistent with the rate filing information in HIOS?

A. Yes. CMS requires states to verify that all rate information submitted to HIOS (in URR, RRJ and PM) matches the rate information submitted in SERFF. The Department, in turn, requires the carriers to confirm this information in writing, via email.

Student Health Plans (SHP)

Q16. Where can carriers find the New Jersey rate filing requirements for Student Health Plans (SHP)?

A. N.J.S.A. 17B:27A-9 and N.J.A.C. 11:20-6.3 (IHC) contain the rate filing requirements for carriers that offer individual health benefits plans. Order A16-106 addresses the rate filing requirements specifically for SHP. 

Note: Carriers are responsible for submitting related SHP policy form filings for each rate filing, in a separate SERFF submission, and for including the policy form SERFF tracking # in the corresponding rate filing submission.

Q17. Do these requirements apply to all SHP rate filings?

A. Yes. The requirements apply to all SHP plan offerings.

Q18. NEW Does the Department use a checklist when reviewing SHP rate filings?

A. Yes. The checklists may be accessed here: SHP Checklist.

Q19. What are the due dates for SHP rate filings?

A. SHP rate filings, must be submitted, via SERFF, at least 90 days prior to the effective date of the rates.

Q20. How can carriers get answers to SHP-specific rate filing questions?

A. E-mail questions to

Contact Information

Q21. What if carriers have other questions?

A. Questions should be addressed to the following:

Joanne Petto (
Don Henson (
Gary Weiss (

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