PART 148—REQUIREMENTS FOR THE INDIVIDUAL HEALTH INSURANCE MARKET Authority: 42 U.S.C. 300gg through 300gg-63, 300gg-11 300gg-91, and 300-gg92, as amended. Source: 62 FR 16995, Apr. 8, 1997, unless otherwise noted. Subpart A—General Provisions § 148.101 Basis and purpose. This part implements sections 2741 through 2763 and 2791 and 2792 of the PHS Act. Its purpose is to guarantee the renewability of all coverage in the individual market. It also provides certain protections for mothers and newborns with respect to coverage for hospital stays in connection with childbirth and protects all individuals and family members who have, or seek, individual health insurance coverage from discrimination based on genetic information. [79 FR 30340, May 27, 2014] § 148.102 Scope and applicability date. (a) Scope and applicability. (2) The requirements that pertain to guaranteed renewability for all individuals, to protections for mothers and newborns with respect to hospital stays in connection with childbirth, and to protections against discrimination based on genetic information apply to all issuers of individual health insurance coverage in the State. (b) Applicability dates. short-term, limited-duration insurance short-term, limited-duration insurance short-term, limited-duration insurance [79 FR 30340, May 27, 2014, as amended at 81 FR 75327, Oct. 31, 2016; 83 FR 38243, Aug. 3, 2018; 89 FR 23419, Apr. 3, 2024] Subpart B—Requirements Relating to Access and Renewability of Coverage § 148.120 Guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage. The rules for guaranteeing the availability of individual health insurance coverage to certain eligible individuals with prior group coverage have been superseded by the requirements of § 147.104 of this subchapter, which set forth Federal requirements for guaranteed availability of coverage in the group and individual markets. [79 FR 30340, May 27, 2014] § 148.122 Guaranteed renewability of individual health insurance coverage. (a) Applicability. See (b) General rules. (2) Medicare entitlement or enrollment is not a basis to nonrenew an individual's health insurance coverage in the individual market under the same policy or contract of insurance. (c) Exceptions to renewing coverage. (1) Nonpayment of premiums. (2) Fraud. (3) Termination of product. (4) Movement outside the service area. (5) Association membership ceases. (d) Discontinuing a particular type of coverage. (1) Provides notice in writing, in a form and manner specified by the Secretary, to each individual provided coverage of that type of health insurance at least 90 calendar days before the date the coverage will be discontinued. (2) Offers to each covered individual, on a guaranteed issue basis, the option to purchase any other individual health insurance coverage currently being offered by the issuer for individuals in that market. (3) Acts uniformly without regard to any health status-related factor of covered individuals or dependents of covered individuals who may become eligible for coverage. (e) Discontinuing all coverage. (1) Provides notice in writing to the applicable State authority and to each individual of the discontinuation at least 180 days before the date the coverage will expire. (2) Discontinues and does not renew all health insurance policies it issues or delivers for issuance in the State in the individual market. (3) Acts uniformly without regard to any health status-related factor of covered individuals or dependents of covered individuals who may become eligible for coverage. (4) For purposes of this paragraph (e), subject to applicable State law, an issuer will not be considered to have discontinued offering all health insurance coverage in a market in a State if— (i) The issuer (in this paragraph referred to as the initial issuer) or, if the issuer is a member of a controlled group, any other issuer that is a member of such controlled group, offers and makes available in the applicable market in the State at least one product that is considered in accordance with § 144.103 of this subchapter to be the same product as a product the initial issuer had been offering in such market in such State; or (ii) The issuer— (A) Offers and makes available at least one product (in paragraphs (e)(4)(ii)(A) through (C) of this section referred to as the new product) in the applicable market in the State, even if such product is not considered in accordance with § 144.103 of this subchapter to be the same product as a product the issuer had been offering in the applicable market in the State (in paragraphs (e)(4)(ii)(A) through (C) of this section referred to as the discontinued product); (B) Subjects such new product or products to the applicable process and requirements established under part 154 of this title as if such process and requirements applied with respect to that product or products, to the extent such process and requirements are otherwise applicable to coverage of the same type and in the same market; and (C) Reasonably identifies the discontinued product or products that correspond to the new product or products for purposes of the process and requirements applied pursuant to paragraph (e)(4)(ii)(B) of this section. (5) For purposes of this section, the term controlled group means a group of two or more persons that is treated as a single employer under sections 52(a), 52(b), 414(m), or 414(o) of the Internal Revenue Code of 1986, as amended, or a narrower group as may be provided by applicable State law. (f) Prohibition on market reentry. (g) Exception for uniform modification of coverage. (2) For purposes of paragraph (g) of this section, modifications made uniformly and solely pursuant to applicable Federal or State requirements are considered a uniform modification of coverage if: (i) The modification is made within a reasonable time period after the imposition or modification of the Federal or State requirement; and (ii) The modification is directly related to the imposition or modification of the Federal or State requirement. (3) For purposes of paragraph (g) of this section, other types of modifications made uniformly are considered a uniform modification of coverage if the health insurance coverage for the product meets all of the following criteria: (i) The product is offered by the same health insurance issuer (within the meaning of section 2791(b)(2) of the PHS Act), or if the issuer that is a member of a controlled group (as described in paragraph (e)(5) of this section), any other health insurance issuer that is a member of such controlled group; (ii) The product is offered as the same product network type (for example, health maintenance organization, preferred provider organization, exclusive provider organization, point of service, or indemnity); (iii) The product continues to cover at least a majority of the same service area; (iv) Within the product, each plan has the same cost-sharing structure as before the modification, except for any variation in cost sharing solely related to changes in cost and utilization of medical care, or to maintain the same metal tier level described in sections 1302(d) and (e) of the Affordable Care Act; and (v) The product provides the same covered benefits, except for any changes in benefits that cumulatively impact the rate for any plan within the product within an allowable variation of ±2 percentage points (not including changes pursuant to applicable Federal or State requirements). (4) A State may only broaden the standards in paragraphs (g)(3)(iii) and (iv) of this section. (h) Application to coverage offered only through associations. (i) Notice of renewal of coverage. (Approved by the Office of Management and Budget under control number 0938-0703) [62 FR 16998, Apr. 8, 1997; 62 FR 31696, June 10, 1997, as amended at 62 FR 35906, July 2, 1997; 79 FR 30340, May 27, 2014; 79 FR 42986, July 24, 2014; 79 FR 53004, Sept. 5, 2014; 81 FR 94174, Dec. 22, 2016; 84 FR 17561, Apr. 25, 2019] § 148.124 Certification and disclosure of coverage. (a) General rule. See (b) Applicability. [79 FR 30341, May 27, 2014] § 148.126 Determination of an eligible individual. The rules for guaranteeing the availability of individual health insurance coverage to certain eligible individuals with prior group coverage have been superseded by the requirements of § 147.104 of this subchapter, which set forth Federal requirements for guaranteed availability of coverage in the group and individual markets. [79 FR 30341, May 27, 2014] § 148.128 State flexibility in individual market reforms—alternative mechanisms. The rules for a State to implement an acceptable alternative mechanism for purposes of guaranteeing the availability of individual health insurance coverage to certain eligible individuals with prior group coverage have been superseded by the requirements of § 147.104 of this subchapter, which set forth Federal requirements for guaranteed availability of coverage in the group and individual markets. [79 FR 30341, May 27, 2014] Subpart C—Requirements Related to Benefits § 148.170 Standards relating to benefits for mothers and newborns. (a) Hospital length of stay General rule. (i) 48 hours following a vaginal delivery; or (ii) 96 hours following a delivery by cesarean section. (2) When stay begins Delivery in a hospital. (ii) Delivery outside a hospital. (3) Examples. Example 1. (i) Facts. (ii) Conclusion. Example 1 Example 2. (i) Facts. (ii) Conclusion. Example 2 Example 3. (i) Facts. (ii) Conclusion. Example 3 (4) Authorization not required In general. (ii) Example. Example. (i) Facts. (ii) Conclusion. Example (5) Exceptions Discharge of mother. (ii) Discharge of newborn. (iii) Attending provider defined. (iv) Example. Example. (i) Facts. (ii) Conclusion. Example (b) Prohibitions With respect to mothers In general. (A) Deny a mother or her newborn child eligibility or continued eligibility to enroll in or renew coverage solely to avoid the requirements of this section; or (B) Provide payments (including payments-in-kind) or rebates to a mother to encourage her to accept less than the minimum protections available under this section. (ii) Examples. Example 1. (i) Facts. (ii) Conclusion. Example 1, Example 2. (i) Facts. (ii) Conclusion. Example 2, (2) With respect to benefit restrictions In general. (ii) Example. Example. (i) Facts. (ii) Conclusion. Example, (3) With respect to attending providers. (i) Penalize (for example, take disciplinary action against or retaliate against), or otherwise reduce or limit the compensation of, an attending provider because the provider furnished care to a covered individual in accordance with this section; or (ii) Provide monetary or other incentives to an attending provider to induce the provider to furnish care to a covered individual in a manner inconsistent with this section, including providing any incentive that could induce an attending provider to discharge a mother or newborn earlier than 48 hours (or 96 hours) after delivery. (c) Construction. (1) Hospital stays not mandatory. (i) Give birth in a hospital; or (ii) Stay in the hospital for a fixed period of time following the birth of her child. (2) Hospital stay benefits not mandated. (3) Cost-sharing rules In general. (ii) Examples. Example 1. (i) Facts. (ii) Conclusion. Example 1 Example 2. (i) Facts. (ii) Conclusion. Example 2, (4) Compensation of attending provider. (5) Applicability. (d) Notice requirement. (1) Required statement. The insurance contract must disclose information that notifies covered individuals of their rights under this section. (2) Disclosure notice. To meet the disclosure requirements set forth in paragraph (d)(1) of this section, the following disclosure notice must be used: Statement of Rights Under the Newborns' and Mothers' Health Protection Act Under federal law, health insurance issuers generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the issuer may pay for a shorter stay if the attending provider ( e.g. Also, under federal law, issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, an issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact your issuer. (3) Timing of disclosure. (4) Exception. (e) Applicability in certain states Health insurance coverage. (i) The state law requires the coverage to provide for at least a 48-hour hospital length of stay following a vaginal delivery and at least a 96-hour hospital length of stay following a delivery by cesarean section. (ii) The state law requires the coverage to provide for maternity and pediatric care in accordance with guidelines that relate to care following childbirth established by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, or any other established professional medical association. (iii) The state law requires, in connection with the coverage for maternity care, that the hospital length of stay for such care is left to the decision of (or is required to be made by) the attending provider in consultation with the mother. State laws that require the decision to be made by the attending provider with the consent of the mother satisfy the criterion of this paragraph (e)(1)(iii). (2) Relation to section 2762(a) of the PHS Act. (f) Applicability date. [73 FR 62427, Oct. 20, 2008] § 148.180 Prohibition of discrimination based on genetic information. (a) Definitions. Collect Family member Genetic information Genetic services Genetic test Manifestation or manifested Preexisting condition exclusion Underwriting purposes (b) Prohibition on genetic information as a condition of eligibility In general. (2) Rule of construction. (3) Examples. Example 1. (i) Facts. A S M. M A S. A S M S. (ii) Conclusion. Example 1, M S S Example 2. (i) Facts. Example 1, S S M S' M S. (ii) Conclusion. Example 2, M S S M S. M S (c) Prohibition on genetic information in setting premium rates In general. (2) Rule of construction. (ii) The manifestation of a disease or disorder in one individual cannot also be used as genetic information about other individuals covered under the policy issued to that individual and to further increase premium amounts. (3) Examples. Example 1. (i) Facts. B N. N B B' N B' N' B' (ii) Conclusion. Example 1, N B' B. Example 2. (i) Facts. Example 1, B' N, B B N B B (ii) Conclusion. Example 2, N B' B' B. B N B' (d) Prohibition on genetic information as preexisting condition In general. (2) Rule of construction. (3) Examples: Example 1. (i) Facts. C O. C O C C' (ii) Conclusion. Example 1, O C C Example 2. (i) Facts. D P. D P' D, P D' D' P D D D' (ii) Conclusion. Example 2, D (e) Limitation on requesting or requiring genetic testing General rule. (2) Health care professional may recommend a genetic test. (3) Examples. Example 1. (i) Facts. E E' E E' E (ii) Conclusion. Example 1, E. E Example 2. (i) Facts. F F F F F (ii) Conclusion. Example 2, F. F (4) Determination regarding payment In general. (ii) Limitation. (iii) Examples. See (5) Research exception. (i) Research in accordance with Federal regulations and applicable State or local law or regulations. (ii) Written request for participation in research. (A) Compliance with the request is voluntary; and (B) Noncompliance will have no effect on eligibility for benefits (as described in paragraph (b) of this section) or premium amounts (as described in paragraph (c) of this section). (iii) Prohibition on underwriting. (iv) Notice to Federal agencies. (f) Prohibitions on collection of genetic information For underwriting purposes General rule. See (ii) Underwriting purposes defined. underwriting purposes (A) Rules for, or determination of, eligibility (including enrollment and continued eligibility) for benefits under the coverage; (B) The computation of premium amounts under the coverage; (C) The application of any preexisting condition exclusion under the coverage; and (D) Other activities related to the creation, renewal, or replacement of a contract of health insurance. (iii) Medical appropriateness. See (2) Prior to or in connection with enrollment In general. (ii) Incidental collection exception In general. (B) Limitation. (iii) Examples. Example 1. (i) Facts. G Q. Q' G Q (ii) Conclusion. Example 1, G' G. Q Q' Q' Q Example 2. (i) Facts. H R. R' R. R H, H' R. (ii) Conclusion. Example 2, R' H, H. R' R' H' H Example 3. (i) Facts. S T. S T' S T S T S T' (ii) Conclusion. Example 3, S' S (g) Examples regarding determinations of medical appropriateness. Example 1. (i) Facts. I U I' I' I U U I (ii) Conclusion. Example 1, U U I' U' Example 2. (i) Facts. J V J J V V J (ii) Conclusion. Example 2, V V Example 3. (i) Facts. K K' K K W 2 W (ii) Conclusion. Example 3, W K' K 2 W K. (h) Applicability date. [74 FR 51693, Oct. 7, 2009] Subpart D—Preemption; Excepted Benefits § 148.210 Preemption. (a) Scope. (2) Sections 2741 through 2763 and 2791 of the PHS Act cannot be construed to affect or modify the provisions of section 514 of ERISA. (b) Regulation of insurance issuers. § 148.220 Excepted benefits. The requirements of this part and part 147 of this subchapter do not apply to any individual coverage in relation to its provision of the benefits described in paragraphs (a) and (b) of this section (or any combination of the benefits). (a) Benefits excepted in all circumstances. (1) Coverage only for accident (including accidental death and dismemberment). (2) Disability income insurance. (3) Liability insurance, including general liability insurance and automobile liability insurance. (4) Coverage issued as a supplement to liability insurance. (5) Workers' compensation or similar insurance. (6) Automobile medical payment insurance. (7) Credit-only insurance (for example, mortgage insurance). (8) Coverage for on-site medical clinics. (9) Travel insurance, within the meaning of § 144.103 of this subchapter. (b) Other excepted benefits. (1) Limited scope dental or vision benefits. These benefits are dental or vision benefits that are limited in scope to a narrow range or type of benefits that are generally excluded from benefit packages that combine hospital, medical, and surgical benefits. (2) Long-term care benefits. These benefits are benefits that are either— (i) Subject to State long-term care insurance laws; (ii) For qualified long-term care insurance services, as defined in section 7702B(c)(1) of the Code, or provided under a qualified long-term care insurance contract, as defined in section 7702B(b) of the Code; or (iii) Based on cognitive impairment or a loss of functional capacity that is expected to be chronic. (3) Coverage only for a specified disease or illness (for example, cancer policies) if the policies meet the requirements of § 146.145(b)(4)(ii)(B) and (C) of this subchapter regarding noncoordination of benefits. (4) Hospital indemnity or other fixed indemnity insurance only if— (i) There is no coordination between the provision of benefits and an exclusion of benefits under any other health coverage; (ii) The benefits are paid in a fixed dollar amount per period of hospitalization or illness and/or per service (for example, $100/day or $50/visit) regardless of the amount of expenses incurred and without regard to the amount of benefits provided with respect to the event or service under any other health coverage; and (iii)(A) For coverage periods beginning on or after January 1, 2025, the issuer displays prominently on the first page (in either paper or electronic form, including on a website) of any marketing, application, and enrollment or reenrollment materials that are provided at or before the time an individual has the opportunity to apply, enroll or reenroll in coverage, and on the first page of the policy, certificate, or contract of insurance, in at least 14-point font, the language in the following notice: (B) For coverage periods beginning on or after January 1, 2015, and prior to January 1, 2025, the issuer continues to follow the notice provision in 45 CFR 148.220(b)(4)(iv), revised as of October 1, 2023. (iv) If any provision of this paragraph (b)(4) is held to be invalid or unenforceable by its terms, or as applied to any entity or circumstance, or stayed pending further agency action, the provision shall be construed so as to continue to give the maximum effect to the provision permitted by law, along with other provisions not found invalid or unenforceable, including as applied to entities not similarly situated or to dissimilar circumstances, unless such holding is that the provision is invalid and unenforceable in all circumstances, in which event the provision shall be severable from the remainder of this paragraph (b)(4) and shall not affect the remainder thereof. (5) Medicare supplemental health insurance (as defined under section 1882(g)(1) of the Social Security Act. 42 U.S.C. 1395ss, also known as Medigap or MedSupp insurance). The requirements of this part 148 (including genetic nondiscrimination requirements), do not apply to Medicare supplemental health insurance policies. However, Medicare supplemental health insurance policies are subject to similar genetic nondiscrimination requirements under section 104 of the Genetic Information Nondiscrimination Act of 2008 (Pub. L. 110-233), as incorporated into the NAIC Model Regulation relating to sections 1882(s)(2)(e) and (x) of the Act (The NAIC Model Regulation can be accessed at http://www.naic.org. (6) Coverage supplemental to the coverage provided under Chapter 55, Title 10 of the United States Code (also known as CHAMPUS supplemental programs). (7) Similar supplemental coverage provided to coverage under a group health plan (as described in § 146.145(b)(5)(i)(C) of this subchapter). [62 FR 16995, Apr. 8, 1997; 62 FR 31696, June 10, 1997, as amended at 74 FR 51696, Oct. 7, 2009; 79 FR 30341, May 27, 2014; 81 FR 75327, Oct. 31, 2016; 89 FR 23420, Apr. 3, 2024] Subpart E—Grants to States for Operation of Qualified High Risk Pools Source: 68 FR 23414, May 2, 2003, unless otherwise noted. § 148.306 Basis and scope. This subpart implements section 2745 of the Public Health Service Act (PHS Act). It extends grants to States that have qualified high risk pools that meet the specific requirements described in § 148.310. It also provides specific instructions on how to apply for the grants and outlines the grant review and grant award processes. [73 FR 22285, Apr. 25, 2008] § 148.308 Definitions. For the purposes of this subpart, the following definitions apply: Bonus grants CMS Loss Qualified high risk pool (1) Provides to all eligible individuals health insurance coverage (or comparable coverage) that does not impose any preexisting condition exclusion with respect to such coverage for all eligible individuals, except that it may provide for enrollment of eligible individuals through an acceptable alternative mechanism (as defined for purposes of section 2744 of the PHS Act) that includes a high risk pool as a component; and (2) Provides for premium rates and covered benefits for such coverage consistent with standards included in the NAIC Model Health Plan for Uninsurable Individuals Act that was in effect at the time of the enactment of the Health Insurance Portability and Accountability Act of 1996 (August 21, 1996) but only if the model has been revised in State regulations to meet all of the requirements of this part and title 27 of the PHS Act. Standard risk rate State State fiscal year, [68 FR 23414, May 2, 2003, as amended at 69 FR 15700, Mar. 26, 2004; 72 FR 41236, July 27, 2007; 73 FR 22285, Apr. 25, 2008] § 148.310 Eligibility requirements for a grant. A State must meet all of the following requirements to be eligible for a grant: (a) The State has a qualified high risk pool as defined in § 148.308. (b) The pool restricts premiums charged under the pool to no more than 200 percent of the premium for applicable standard risk rates for the State. (c) The pool offers a choice of two or more coverage options through the pool. (d) The pool has in effect a mechanism reasonably designed to ensure continued funding of losses incurred by the State after the end of each fiscal year for which the State applies for Federal Funding in fiscal year (FY) 2005 through FY 2010 in connection with the operation of the pool. (e) The pool has incurred a loss in a period described in § 148.314. (f) In the case of a qualified high risk pool in a State that charges premiums that exceed 150 percent of the premium for applicable standard risks, the State will use at least 50 percent of the amount of the grant provided to the State to reduce premiums for enrollees. (g) In no case will the aggregate amount allotted and made available to the U.S. Territories for a fiscal year exceed $1,000,000 in total. (h) Bonus grant funding must be used for one or more of the following benefits: (1) Low income premium subsidies; (2) Reduction in premium trends, actual premium or other cost-sharing requirements; (3) An expansion or broadening of the pool of individuals eligible for coverage, such as through eliminating waiting lists, increasing enrollment caps, or providing flexibility in enrollment rules; (4) Less stringent rules or additional waiver authority with respect to coverage of pre-existing conditions; (5) Increased benefits; and (6) The establishment of disease management programs. [68 FR 23414, May 2, 2003, as amended at 72 FR 41236, July 27, 2007; 73 FR 22285, Apr. 25, 2008] § 148.312 Amount of grant payment. (a) An eligible State may receive a grant to fund up to 100 percent of the losses incurred in the operation of its qualified high risk pool during the period for which it is applying or a lesser amount based on the limits of the allotment under the formula. (b) Funds will be allocated in accordance with this paragraph to each State that meets the eligibility requirements of § 148.310 and files an application in accordance with § 148.316. The amount will be divided among the States that apply and are awarded grants according to the allotment rules that generally provide that: 40 percent will be equally divided among those States; 30 percent will be divided among States and territories based on their number of uninsured residents in the State during the specified year as compared to all States that apply; and 30 percent will be divided among States and territories based on the number of people in State high risk pools during the specified year as compared to all States that apply. For purposes of this paragraph: (1) The number of uninsured individuals is calculated for each eligible State by taking a 3-year average of the number of uninsured individuals in that State in the Current Population Survey (CPS) of the Census Bureau during the period for which it is applying. The 3-year average will be calculated using numbers available as of March 1 of each year. (2) The number of individuals enrolled in health care coverage through the qualified high risk pool of the State will be determined by attestation by the State in its grant application and verified for reasonability by the Secretary through acceptable industry data sources. (c) The amount awarded to each eligible State will be the lesser of the 50 percent of losses incurred by its qualified risk pool for the fiscal year in question or its allotment under the formula. (d) One-third of the total appropriation will be available for the bonus grants. In no case will a State for a fiscal year receive bonus grants that exceed 10 percent of the total allotted funds for bonus grants. [68 FR 23414, May 2, 2003, as amended at 69 FR 15700, Mar. 26, 2004; 72 FR 41237, July 27, 2007; 73 FR 22285, Apr. 25, 2008] § 148.314 Periods during which eligible States may apply for a grant. (a) General rule. (b) Maximum number of grants. (c) Deadline for submitting grant applications. (d) Distribution of grant funds. (e) Grant allocations. (1) In no case will a State receive funds greater than 100 percent of their losses. (2) If any excess funds remain after the initial calculation, these excess funds will be proportionately redistributed to the States whose allocations have not exceeded 100 percent of their losses. [73 FR 22285, Apr. 25, 2008] § 148.316 Grant application instructions. Funding for FY 2008, FY 2009, and FY 2010 under the Extension Act requires the subsequent enactment of appropriations authority. Funding was appropriated for Federal FY 2006. States will be unable to apply for FY 2008 through FY 2010 grants unless and until such funding becomes available. (a) Application for operational losses. (1) History and description of the qualified high risk pool. (i) Brief history, including date of inception. (ii) Enrollment criteria (including provisions for the admission of eligible individuals as defined in § 148.103) and number of enrollees. (iii) Description of how coverage is provided administratively in the qualified high risk pool (that is, self-insured, through a private carrier, etc.). (iv) Benefits options and packages offered in the qualified high risk pool to both eligible individual (as defined in § 148.103) and other applicants. (v) Outline of plan benefits and coverage offered in the pool. Provide evidence that the level of plan benefits is consistent with either Alternative One or Alternative Two in Section 8 of the NAIC Model Health Plan for Uninsurable Individuals Act. See appendix for the text of Section 8 of the NAIC Model. (vi) Premiums charged (in terms of dollars and in percentage of standard risk rate) and other cost-sharing mechanisms, such as co-pays and deductibles, imposed on enrollees (both eligible individuals (as defined in § 148.103) and non-eligible individuals if a distinction is made). (vii) How the standard risk rate for the State is calculated and when it was last calculated. (viii) Revenue sources for the qualified high risk pool, including current funding mechanisms and, if different, future funding mechanisms. Provide current projections of future income. (ix) Copies of all governing authorities of the pool, including statutes, regulations and plan of operation. (2) Accounting of risk pool losses. (3) Bonus grants for supplemental consumer benefits. (i) A narrative description of one or more of the following of the supplemental consumer benefits to be provided to enrollees and/or potential enrollees in the high risk pool: (A) Low income premium subsidies; (B) Reduction in premium trends, actual premium or other cost-sharing requirements; (C) An expansion or broadening of the pool of individuals eligible for coverage, such as through eliminating waiting lists, increasing enrollment caps, or providing flexibility in enrollment; (D) Less stringent rules, or additional waiver authority with respect to coverage of pre-existing conditions; (E) Increased benefits; and (F) The establishment of disease management programs. (ii) A description of the population or subset population that will be eligible for the supplemental consumer benefits. (iii) A projected budget for the use of bonus grant funds using the SF 424 A. (4) Contact person. (b) Standard form application kit—(1) Forms. (i) The following standard forms must be completed with an original signature and enclosed as part of the application package: SF-424 Application for Federal Assistance. SF-424A Budget Information. SF-424B Assurances Non-Construction Programs. SF-LLL Disclosure of Lobbying Activities Biographical Sketch. (ii) These forms can be accessed from the following Web site: http://www.grants.gov. (2) Other narrative. 1/2 (c) Application submission. http://www.grants.gov. (d) Application deadlines. (2) Deadline for States to submit an application for losses incurred in their fiscal year 2005. (3) Deadline for States to submit an application for losses incurred in their fiscal year 2006. (4) Deadline for States to submit an application for losses incurred in their fiscal year 2007. (5) Deadline for States to submit an application for losses incurred in their fiscal year 2008. (6) Deadline for States to submit an application for losses incurred in their fiscal year 2009. (e) Where to submit an application. http://www.grants.gov. [68 FR 23414, May 2, 2003, as amended at 69 FR 15701, Mar. 26, 2004; 72 FR 41237, July 27, 2007; 73 FR 22286, Apr. 25, 2008] § 148.318 Grant application review. (a) Executive Order 12372. (b) Review team. (c) Eligibility criteria. (d) Review criteria. (1) Documentation of expenses incurred during operation of the qualified high risk pool. (2) Funding mechanism. [68 FR 23414, May 2, 2003, as amended at 72 FR 41238, July 27, 2007; 73 FR 22286, Apr. 25, 2008] § 148.320 Grant awards. (a) Notification and award letter. (2) If the State applicant is awarded a grant, the award letter will contain the following terms and conditions: (i) All funds awarded to the grantee under this program must be used exclusively for the operation of a qualified high risk pool that meets the eligibility requirements for this program. (ii) The grantee must keep sufficient records of the grant expenditures for audit purposes (see part 92 of this title). (iii) The grantee will be required to submit quarterly progress and financial reports under part 92 of this title and in accordance with section 2745(f) of the Public Health Service Act, requiring the Secretary to make an annual report to Congress that includes information on the use of these grant funds by States. (b) Grantees letter of acceptance. [68 FR 23414, May 2, 2003, as amended at 72 FR 41238, July 27, 2007; 73 FR 22286, Apr. 25, 2008]