['Employee Benefits']
['Health Plans']
12/05/2023
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(a) Application package. Each State must compile an application package that documents that it has met the requirements for a grant. If a risk pool entity applies on behalf of a State, it must provide documentation that it has been delegated appropriate authority by the State. At a minimum, the application package must include a completed standard form application kit (see paragraph (b) of this section) along with the following information:
(a)(1) History and description of the qualified high risk pool. Provide a detailed description of the qualified high risk pool that includes the following:
(a)(1)(i) Brief history, including date of inception.
(a)(1)(ii) Enrollment criteria (including provisions for the admission of eligible individuals as defined in §148.103) and number of enrollees.
(a)(1)(iii) Description of how coverage is provided administratively in the qualified high risk pool (that is, self-insured, through a private carrier, etc.).
(a)(1)(iv) Benefits options and packages offered in the qualified high risk pool to both eligible individual (as defined in §148.103) and other applicants.
(a)(1)(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.
(a)(1)(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).
(a)(1)(vii) How the standard risk rate for the State is calculated and when it was last calculated.
(a)(1)(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.
(a)(1)(ix) Copies of all governing authorities of the pool, including statutes, regulations and plan of operation.
(a)(2) Accounting of risk pool losses. Provide a detailed accounting of claims paid, administrative expenses, and premiums collected for the fiscal year for which the grant is being requested. Indicate the timing of the fiscal year upon which the accounting is based. Provide the methodology of projecting losses and expenses, and include current projections of future operating losses (this information is needed to judge compliance with the requirements in §148.310(d)).
(a)(3) Contact person. Identify the name, position title, address, e-mail address, and telephone number of the person to contact for further information and questions.
(b) Standard form application kit—
(b)(1) Forms.
(b)(1)(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 Program
SF–LLL Disclosure of Lobbying Activities Biographical Sketch
Additional Assurances
(b)(1)(ii) These forms can be downloaded from the following Web site:
http://www.cms.hhs.gov/researchers/priorities/grants.asp.
(b)(2) Other narrative. All other narrative in the application must be submitted on 8 1/2 x 11" white paper.
(c) Submission of application package.
(c)(1) Applicants are required to submit an original and two copies of the application. Submissions by facsimile (fax) transmissions will not be accepted.
(c)(2) Applications mailed through the U.S. Postal Service or a commercial delivery service will be considered “on time” if received by the close of business on the closing date, or postmarked (first class mail) by the date specified in the paragraph (d) of this section. If express, certified, or registered mail is used, the applicant should obtain a legible dated mailing receipt from the U.S. Postal Service. Private metered postmarks are not acceptable as proof of timely mailings.
(d) Application deadlines—
(d)(1) Deadline for States to submit an application for losses incurred in their fiscal year 2002. States must submit an application to us by no later than September 30, 2003.
(d)(2) Deadline for States to submit an application for losses incurred in their fiscal year 2003. States must submit an application to us by no later than June 30, 2004.
(d)(3) Deadline for States to submit an application for losses incurred in their fiscal year 2004. States must submit an application to us by no later than June 30, 2005.
(e) Where to submit an application. All initial applications and supplemental applications must be submitted to:
Centers for Medicare & Medicaid Services, Acquisition and Grants Group, Mail Stop C2–21–15, 7500 Security Boulevard, Baltimore, MD 21244–1850, Attn: Nicole Nicholson.
[68 FR 23414, May 2, 2003, as amended at 69 FR 15701, Mar. 26, 2004]
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