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Notes

45 C.F.R. §§ 158.606–158.610

5 sections in range

§158.606. Amount of penalty—general.

45 C.F.R. § 158.606

A civil monetary penalty for each violation of § 158.602 of this subpart may not exceed $100 as adjusted annually under 45 CFR part 102 for each day, for each responsible entity, for each individual affected by the violation. Penalties imposed under this part are in addition to any other penalties prescribed or allowed by law.
Notes, amendments, and revision history

Amendments

[75 FR 74921, Dec. 1, 2010, as amended at 81 FR 61581, Sept. 6, 2016]

Authority

Authority: 42 U.S.C. 300gg-18.

Source

Source: 75 FR 74921, Dec. 1, 2010, unless otherwise noted.

Amendments

[75 FR 74921, Dec. 1, 2010, as amended at 81 FR 61581, Sept. 6, 2016]

§158.607. Factors HHS uses to determine the amount of penalty.

45 C.F.R. § 158.607

In determining the amount of any penalty, HHS may take into account the following:
(a)
The entity's previous record of compliance. This may include any of the following:
(1)
Any history of prior violations by the responsible entity, including whether, at any time before determination of the current violation(s), HHS or any State found the responsible entity liable for civil or administrative sanctions in connection with a violation of Affordable Care Act requirements regarding minimum loss ratios.
(2)
Evidence that the responsible entity has never had a complaint for noncompliance with Affordable Care Act requirements regarding MLRs filed with a State or HHS.
(3)
Such other factors as justice may require.
(b)
The gravity of the violation. This may include any of the following:
(1)
The frequency of the violation, taking into consideration whether any violation is an isolated occurrence, represents a pattern, or is widespread.
(2)
The level of financial and other impacts on affected individuals.
(3)
Other factors as justice may require.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 300gg-18.

Source

Source: 75 FR 74921, Dec. 1, 2010, unless otherwise noted.

§158.608. Determining the amount of the penalty—mitigating circumstances.

45 C.F.R. § 158.608

For every violation subject to a civil monetary penalty, if there are substantial or several mitigating circumstances, the aggregate amount of the penalty is set at an amount sufficiently below the maximum permitted by § 158.606 of this subpart to reflect that fact. As guidelines for taking into account the factors listed in § 158.607 of this subpart, HHS considers the following:
(a)
Record of prior compliance. It should be considered a mitigating circumstance if the responsible entity has done any of the following:
(1)
Before receipt of the notice issued under § 158.603 of this subpart, implemented and followed a compliance plan as described in § 158.605(c) of this subpart.
(2)
Had no previous complaints against it for noncompliance.
(b)
Gravity of the violation(s). It should be considered a mitigating circumstance if the responsible entity has done any of the following:
(1)
Made adjustments to its business practices to come into compliance with the requirements of this part so that the following occur:
(i)
Each enrollee adversely affected by the violation has been paid any amount of rebate owed so that, to the extent practicable, that enrollee is in the same position that he, she, or it would have been in had the violation not occurred.
(ii)
The rebate payments are completed in a timely manner.
(2)
Discovered areas of noncompliance without notice from HHS and voluntarily reported that noncompliance, provided that the responsible entity submits the following:
(i)
Documentation verifying that the rights and protections of all individuals adversely affected by the noncompliance have been restored; and
(ii)
A plan of correction to prevent future similar violations.
(3)
Demonstrated that the violation is an isolated occurrence.
(4)
Demonstrated that the financial and other impacts on affected individuals is negligible or nonexistent.
(5)
Demonstrated that the noncompliance is correctable and that a high percentage of the violations were corrected.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 300gg-18.

Source

Source: 75 FR 74921, Dec. 1, 2010, unless otherwise noted.

§158.609. Determining the amount of penalty—aggravating circumstances.

45 C.F.R. § 158.609

For every violation subject to a civil monetary penalty, if there are substantial or several aggravating circumstances, HHS may set the aggregate amount of the penalty at an amount sufficiently close to or at the maximum permitted by § 158.606 of this subpart to reflect that fact. HHS considers the following circumstances to be aggravating circumstances:
(a)
The frequency of violation indicates a pattern of widespread occurrence.
(b)
The violation(s) resulted in significant financial and other impacts on the average affected individual.
(c)
The entity does not provide documentation showing that substantially all of the violations were corrected.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 300gg-18.

Source

Source: 75 FR 74921, Dec. 1, 2010, unless otherwise noted.

§158.610. Determining the amount of penalty—other matters as justice may require.

45 C.F.R. § 158.610

HHS may take into account other circumstances of an aggravating or mitigating nature if, in the interests of justice, they require either a reduction or an increase of the penalty in order to assure the achievement of the purposes of this part, and if those circumstances relate to the entity's previous record of compliance or the gravity of the violation.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 300gg-18.

Source

Source: 75 FR 74921, Dec. 1, 2010, unless otherwise noted.