                                 CODE OF VIRGINIA

COMMONWEALTH HEALTH REINSURANCE PROGRAM; ESTABLISHED (§ 38.2-6602)

A. The Commission shall implement a reinsurance program, known as the
Commonwealth Health Reinsurance Program. Implementation and operation of the
Program is contingent upon approval of the State Innovation Waiver submitted by
the Commission in accordance with &#xA7; 38.2-6606. If the State Innovation
Waiver and federal funding request submitted by the Commission pursuant to
&#xA7; 38.2-6606 are approved, the Commission shall implement and operate the
Program in accordance with this section.

B. The Commission or its designee shall collect or access data from an eligible
carrier as necessary to determine reinsurance payments, according to the data
requirements under subdivision C 1.

   1. Unless an eligible carrier is notified otherwise by the Commission, on a
   quarterly basis during the applicable benefit year, each eligible carrier
   shall report to the Commission its claims costs that exceed the attachment
   point for that benefit year. For each applicable benefit year, the Commission
   shall notify eligible carriers of reinsurance payments to be made for the
   applicable benefit year no later than September 30 of the year following the
   applicable benefit year. By November 15 of the year following the applicable
   benefit year, the Commission shall disburse all applicable reinsurance
   payments to an eligible carrier.

   2. For the 2023 benefit year and each benefit year thereafter, the Commission
   shall establish and publish the payment parameters for the applicable benefit
   year by May 1 of the year immediately preceding the applicable benefit year.
   In setting the payment parameters under this subsection, the Commission shall
   (i) set such payment parameters at levels designed to achieve the premium
   reduction target established in the general appropriation act or, if such
   target is not established in the general appropriation act, the premium
   reduction target of the benefit year prior to the applicable benefit year and
   (ii) consider the following factors: (a) stabilized or reduced premium rates
   in the individual market, (b) increased participation in the individual
   market, (c) improved access to health care services and their providers for
   enrolled individuals, (d) mitigation of the impact high-risk individuals have
   on premium rates in the individual market, (e) the availability of any federal
   funding available for the Program, and (f) the total amount available to fund
   the Program.

   3. If the Commission determines that all reinsurance payments for a covered
   person&#8217;s covered benefits requested under the Program by eligible
   carriers for a benefit year will not be equal to the amount of funding
   allocated to the Program, the Commission shall determine a uniform pro rata
   adjustment to be applied to all such requests for reinsurance payments.

C. A carrier that meets the requirement of this subsection and subsection D
shall be eligible to request reinsurance payments from the Program. An eligible
carrier shall make requests for reinsurance payments in accordance with the
requirements established by the Commission.

   1. To receive reinsurance payments through the Program, an eligible carrier
   shall, by April 30 of the year following the benefit year for which
   reinsurance payments are requested, (i) provide the Commission 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. &#xA7; 18063
   or access to other carrier-specific data if and where necessary and (ii)
   submit to the Commission 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.

   2. An eligible carrier shall maintain documents and records sufficient to
   substantiate the requests for reinsurance payments made pursuant to this
   section for at least five years. An eligible carrier shall also make those
   documents and records available upon request from the Commission for purposes
   of verification, investigation, audit, or other review of reinsurance payment
   requests. The Commission may audit an eligible carrier to assess the
   carrier&#8217;s compliance with this section. The eligible carrier shall
   ensure that its contractors, subcontractors, and agents cooperate with any
   audit under this section.

D. The Commission or its designee shall calculate each reinsurance payment based
on an eligible carrier&#8217;s incurred claims costs for a covered
person&#8217;s covered benefits in the applicable benefit year. If the claims
costs for a covered person&#8217;s covered benefits in the applicable benefit
year do not exceed the attachment point for the applicable benefit year, the
carrier shall not be eligible for a reinsurance payment. If the claims costs
exceed the attachment point for the applicable benefit year, the Commission
shall calculate the reinsurance payment as the product of the coinsurance rate
and the eligible carrier&#8217;s claims costs up to the reinsurance cap. A
carrier shall be ineligible for reinsurance payments for claims costs for a
covered person&#8217;s covered benefits in the applicable benefit year that
exceed the reinsurance cap. The Commission shall ensure that reinsurance
payments made to eligible carriers do not exceed the total amount paid by the
eligible carrier for any eligible claim. An eligible carrier may request that
the Commission reconsider a decision on the carrier&#8217;s request for
reinsurance payments within 21 days after notice of the Commission&#8217;s
decision.

E. The Commission shall require each eligible carrier that participates in the
Program to file with the Commission, by a date and in a form and manner
specified by the Commission by rule, the care management protocols the eligible
carrier will use to manage claims within the payment parameters.

HISTORY: 2021, Sp. Sess. I, c. 480; 2022, cc. 547, 548; 2024, c. 293.