(e) (I) On a quarterly basis during the applicable benefit year, each eligible carrier shall report to the commissioner its claims costs that exceed the attachment point for that benefit year.
(II) For each applicable benefit year, the commissioner shall notify eligible carriers of reinsurance payments to be made for the applicable benefit year no later than June 30 of the year following the applicable benefit year. By August 15 of the year following the applicable benefit year, the commissioner shall disburse all applicable reinsurance payments to an eligible carrier.
(2) (a) For purposes of determining eligibility for and calculating reinsurance payments under the reinsurance program for the 2020 benefit year in order to make private health insurance coverage more accessible and affordable and encourage increased carrier participation in rural parts of the state, the commissioner shall set the payment parameters at amounts to achieve:
(I) A reduction in claims costs of between thirty and thirty-five percent in geographic rating area numbers five and nine;
(II) A reduction in claims costs of between twenty and twenty-five percent in geographic rating area numbers four, six, seven, and eight; and
(III) A reduction in claims costs of between fifteen and twenty percent in geographic rating area numbers one, two, and three.
(a.5) To the greatest extent possible, the commissioner shall set the payment parameters for the 2021 benefit year at amounts to maintain the targeted claims reductions achieved in the 2020 benefit year.
(b) For the 2022 benefit year and each benefit year thereafter, after a stakeholder process, the commissioner shall establish and publish the payment parameters for that benefit year by March 15 of the immediately preceding calendar year. In setting the payment parameters under this subsection (2)(b), the commissioner shall consider the following factors as they apply in each geographic rating area in the state:
(I) Participation and competition by carriers in the individual market;
(II) Enrollment across all income levels and morbidity in the individual market;
(III) Participation and competition by providers; and
(IV) Rates in the individual market.
(c) If the amount of money from funding sources specified in section 10-16-1107 is anticipated to be inadequate to fully fund the payment parameters, the commissioner shall establish new payment parameters within the available money. The commissioner shall allow an eligible carrier to revise an applicable rate filing for the next benefit year based on the final payment parameters established pursuant to this subsection (2)(c) and on actual reinsurance payments received by the eligible carrier.
(3) (a) An eligible carrier that meets the requirements of this subsection (3) and subsection (4) of this section may request reinsurance payments from the reinsurance program.
(b) An eligible carrier must make requests for reinsurance payments in accordance with the requirements established by the commissioner.
(c) To receive reinsurance payments through the reinsurance program, an eligible carrier must, by April 30 of the year following the benefit year for which reinsurance payments are requested:
(I) Provide the commissioner with access to the data within the dedicated data environment established by the eligible carrier under the federal risk adjustment program under 42 U.S.C. sec. 18063; and
(II) Submit to the commissioner an attestation that the carrier has complied with the dedicated data environments, data requirements, establishment and usage of masked enrollee identification numbers, and data submission deadlines.
(d) An eligible carrier shall maintain records sufficient to substantiate the requests for reinsurance payments made pursuant to this section for at least six years. An eligible carrier shall also make those records available upon request from the commissioner for purposes of verification, investigation, audit, or other review of reinsurance payment requests.
(e) The commissioner may have an eligible carrier audited to assess the carrier's compliance with this section. The eligible carrier shall ensure that its contractors, subcontractors, and agents cooperate with any audit under this section.
(4) (a) (I) The commissioner shall calculate each reinsurance payment based on an eligible carrier's incurred claims costs for a covered person's covered benefits in the applicable benefit year. If the claims costs do not exceed the attachment point for the applicable benefit year, the carrier is not eligible for a reinsurance payment.
(II) If the claims costs exceed the attachment point for the applicable benefit year, the commissioner shall calculate the reinsurance payment as the product of the coinsurance rate and the eligible carrier's claims costs, up to the reinsurance cap.
(b) A carrier is ineligible for reinsurance payments for claims costs for a covered person's covered benefits in the applicable benefit year that exceed the reinsurance cap.
(c) The commissioner shall ensure that reinsurance payments made to an eligible carrier do not exceed the total amount paid by the eligible carrier for any eligible claim. Total amount paid by the eligible carrier for any eligible claim means the amount paid by the eligible carrier based on the allowed amount less any deductible, coinsurance, or copayment, as of the time the data are submitted or made accessible under subsection (3)(c) of this section.
(d) An eligible carrier may request that the commissioner reconsider a decision on the carrier's request for reinsurance payments within thirty days after notice of the commissioner's decision. A final action or order of the commissioner under this subsection (4)(d) is subject to judicial review in accordance with section 24-4-106.
(5) In order to promote more cost-effective health-care coverage and to be fair to federal taxpayers by restraining growth in federal spending commitments, the commissioner shall require each eligible carrier that participates in the program to file with the commissioner, by a date and in a form and manner specified by the commissioner by rule, the care management protocols the eligible carrier will use to manage claims within the payment parameters.
