Waiver of Uniform Premium Requirement

20.4.1 – Waiver of Uniform Premium Requirement (Rev. 111, 05-03-13, Effective: 05-03-13, Implementation: 05-03-13) The uniform premium requirement (see 42 CFR 422.100(d)(2)) has been waived for entities offering “800 series” plans under certain circumstances. Under this waiver of the uniform premium requirement, entities offering “800 series” plans serving multiple counties, regions or the nation will be allowed to vary premium and cost sharing between defined market areas within the same employer/union-sponsored group plan. This waiver is contingent on the requirement that the market areas (geographic areas) within the employer-sponsored group plan with premium variation are based on objective market information demonstrating verifiable differences in medical costs between these market areas. The MAO must have documentation validating the medical cost variation in these market areas comprising the plan. The MAOs will be required to retain all of these documents and must provide access to this documentation for inspection or audit by CMS (or its designee) in accordance with the requirements at 42 CFR §422.503(d) and §422.504(d) and (e). Entities offering “800 series” plans that serve multiple counties, which do not represent separate market areas in terms of medical costs, may not utilize this waiver. However, these entities may consider using the plan segmentation rules at §422.262(c)(2) to vary premium between an “800 series” plan’s payment areas (i.e., counties).