Effective Date of Rule: Thirty-one days after filing.

     Purpose: These amendments restore the procedures and processes used by commissioner to review individual rate filings prior to changes made by the legislature in 2000 to the commissioner's authority to review individual health coverage rate filings. Carriers will be required to submit documentation of actuarial formulas, statistics, and assumptions in support of their rates for actuarial review of the commissioner.

     Citation of Existing Rules Affected by this Order: Amending WAC 284-43-910, 284-43-925, 284-43-930, and 284-43-945.

     Statutory Authority for Adoption: RCW 48.02.060, 48.18.110, 48.44.020, 48.44.050, 48.46.060, 48.46.200.

      Adopted under notice filed as WSR 08-15-158 on July 23, 2008.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 4, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 4, Repealed 0.

     Date Adopted: September 25, 2008.

Mike Kreidler

Insurance Commissioner

OTS-1760.1

NEW SECTION
WAC 284-43-901   Authority and purpose.   This subchapter is adopted under the general authority of RCW 48.02.060, 48.44.017, 48.44.020, 48.44.050, 48.46.060, 48.46.062, and 48.46.200. Its purpose is to provide guidelines for the implementation of RCW 48.44.017(2), 48.44.020(3), 48.44.022, 48.44.023, 48.44.040, 48.46.060 (4) and (6), 48.46.062(2), 48.46.064, and 48.46.066 as to the filing of contract forms by health care service contractors and health maintenance organizations and the calculations and evaluations of premium rates for these contracts.

[]

     (1) "Adjusted earned premium" means the amount of "earned premium" the "carrier" would have earned had the "carrier" charged current "premium rates" for all applicable "plans."

     (2) "Annualized earned premium" means the "earned premium" that would be earned in a twelve-month period if earned at the same rate as during the applicable period.

     (3) "Anticipated loss ratio" means the "projected incurred claims" divided by the "projected earned premium."

     (4) "Base rate" means the "premium" for a specific "plan," expressed as a monthly amount per "covered person or subscriber," prior to any adjustments for geographic area, age, family size, wellness activities, tenure, or any other factors as may be allowed.

     (5) "Capitation expenses" means the amount paid to a provider or facility on a per "covered person" basis, or as part of risk-sharing provisions, for the coverage of specified health care services.

     (6) "Carrier" means a health care service contractor or health maintenance organization.

     (7) "Certificate" means the statement of coverage document furnished "subscribers" covered under a "group contract."

     (8) "Claim reserves" means the "claims" that have been reported but not paid plus the "claims" that have not been reported but may be reasonably expected.

     (9) "Claims" means the cost to the "carrier" of health care services provided to a "covered person" or paid to or on behalf of the "covered person" in accordance with the terms of a "plan." This includes "capitation payments" or other similar payments made to providers or facilities for the purpose of paying for health care services for a "covered person."

     (10) "Community rate" means the weighted average of all "premium rates" within a filing with the weights determined according to current enrollment.

     (11) "Contract" means an agreement to provide health care services or pay health care costs for or on behalf of a "subscriber" or group of "subscribers" and such eligible dependents as may be included therein.

     (12) "Contract form" means the prototype of a "contract" and any associated riders and endorsements filed with the commissioner by a health care service contractor or health maintenance organization.

     (13) "Contribution to surplus, contingency charges, or risk charges" means the portion of the "projected earned premium" not associated directly with "claims" or "expenses."

     (14) "Covered person" or "enrollee" has the same meaning as that contained in RCW 48.43.005.

     (15) "Current community rate" means the weighted average of the "community rates" at the renewal or initial effective dates of each plan for the year immediately preceding the renewal period, with weights determined according to current enrollment.

     (16) "Current enrollment" means the monthly average number and demographic makeup of the "covered persons" for the applicable contracts during the most recent twelve months for which information is available to the carrier.

     (17) "Earned premium" means the "premium" plus any rate credits or recoupments, applicable to an accounting period whether received before, during, or after such period.

     (18) "Expenses" means costs that include but are not limited to the following:

     (a) Claim adjudication costs;

     (b) Utilization management costs if distinguishable from "claims";

     (c) Home office and field overhead;

     (d) Acquisition and selling costs;

     (e) Taxes; and

     (f) All other costs except "claims."

     (19) "Experience period" means the most recent twelve-month period from which the carrier accumulates the data to support a filing.

     (20) "Extraordinary expenses" means "expenses" resulting from occurrences atypical of the normal business activities of the "carrier" that are not expected to recur regularly in the near future.

     (21) "Group contract" or "group plan" means an agreement issued to an employer, corporation, labor union, association, trust, or other organization to provide health care services to employees or members of such entities and the dependents of such employees or members.

     (22) "Incurred claims" means "claims" paid during the applicable period plus the "claim reserves" as of the end of the applicable period minus the "claim reserves" as of the beginning of the applicable period. Alternatively, for the purpose of providing monthly data or trend analysis, "incurred claims" may be defined as the current best estimate of the "claims" for services provided during the applicable period.

     (23) "Individual contract" means a "contract" issued to and covering an individual. An "individual contract" may include dependents.

     (24) "Investment earnings" means the income, dividends, and realized capital gains earned on an asset.

     (25) "Loss ratio" means "incurred claims" as a percentage of "earned premiums" before any deductions.

     (26) "Medical care component of the consumer price index for all urban consumers" means the similarly named figure published monthly by the United States Bureau of Labor Statistics.

     (27) "Net worth or reserves and unassigned funds" means the excess of assets over liabilities on a statutory basis.

     (28) "Plan" means a "contract" that is a health benefit plan as defined in RCW 48.43.005 or a "contract" for limited health care services as defined in RCW 48.44.035.

     (29) "Premium" has the same meaning as that contained in RCW 48.43.005.

     (30) "Premium rate" means the "premium" per "subscriber" or "covered person" obtained by adjusting the "base rate" for geographic area, family size, age, wellness activities, or any other factors as may be allowed.

     (31) "Projected earned premium" means the "earned premium" that would be derived from applying the proposed "premium rates" to the current enrollment.

     (32) "Projected incurred claims" means the estimate of "incurred claims" for the rate renewal period based on the current enrollment.

     (33) "Proposed community rate" means the weighted average of the "community rates" at the renewal dates of each plan for the renewal period, with weights determined according to current enrollment.

     (34) "Provider" has the same meaning as that contained in RCW 48.43.005.

     (35) "Rate renewal period" means the period for which the proposed "premium rates" are intended to remain in effect.

     (36) "Rate schedule" means the schedule of all "base rates" for "plans" included in the filing.

     (37) "Requested increase in the community rate" means the amount, expressed as a percentage, by which the "proposed community rate" exceeds the "current community rate."

     (38) "Service type" means the category of service for which "claims" are paid, such as hospital, professional, dental, prescription drug, or other.

     (39) "Small group contracts" or "small group plans" means the class of "group contracts" issued to "small employers," as that term is defined in RCW 48.43.005.

     (40) "Staffing data" means statistics on the number of providers and associated compensation required to provide a fixed number of services or provide services to a fixed number of "covered persons."

     (41) "Subscriber" means a person on whose behalf a "contract" or "certificate" is issued.

     (42) "Unit cost data" means statistics on the cost per health care service provided to a "covered person."

     (43) "Utilization data" means statistics on the number of services used by a fixed number of "covered persons" over a fixed length of time.

[Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200. 05-07-006 (Matter No. R 2004-05), § 284-43-910, filed 3/3/05, effective 4/3/05. Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064 and 48.46.066. 98-04-011 (Matter No. R 97-2), § 284-43-910, filed 1/23/98, effective 3/1/98.]

[Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200. 05-07-006 (Matter No. R 2004-05), § 284-43-925, filed 3/3/05, effective 4/3/05. Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064 and 48.46.066. 98-04-011 (Matter No. R 97-2), § 284-43-925, filed 1/23/98, effective 3/1/98.]

     (1) An actuarially sound estimate of incurred claims. Experience data, assumptions, and justifications of the carrier's projected incurred claims must be provided in a manner consistent with the carrier's rate-making methodology and incorporate the following elements:

     (a) A brief description of the carrier's rate-making methodology, including identification of the data used and the kinds of assumptions and projections made.

     (b) The number of subscribers by family size, or covered persons for the plans included in the filing. These figures must be shown for each month or quarter of the experience period and the prior two periods if not included in previous filings. This data must be presented in aggregate for the plans included in the filing and in aggregate for all of the carrier's plans.

     (c) Earned premium for each month or quarter of the experience period and the prior two periods if not included in previous filings, for the plans included in the filing.

     (d) An estimate of the adjusted earned premium for each month or quarter of the experience period and prior two periods for the plans included in the filing.

     (e) Claims data for each month or quarter of the experience period and the prior two periods. Examples of claims data are incurred claims, capitation payments, utilization data, unit cost data, and staffing data. The specific data elements included in the filing must be consistent with the carrier's rate-making methodology.

     (f) Documentation and justification of any adjustments made to the experience data.

     (g) Documentation and justification of the factors and methods used to forecast incurred claims.

     (2) An actuarially sound estimate of prudently incurred expenses. Experience data, assumptions, and justifications must be provided by the carrier as follows:

     (a) A breakdown of the carrier's expenses allocated or assigned to the plans included in the filing for the experience period or for the period corresponding to the most recent "annual statement";

     (i) An expense breakdown at least as detailed as the annual statement schedule "Underwriting and Investment Exhibit, Part 3, Analysis of Expenses" as revised from time to time;

     (ii) The allocation and assignment methodology used in (a)(i) of this subsection may be based on readily available data and easily applied calculations;

     (b) Identification of any extraordinary experience period expenses; and

     (c) Documentation and justification of the assignment or allocation of expenses to the plans included in the filing; and

     (d) Documentation and justification of forecasted changes in expenses.

     (3) An actuarially sound provision for contribution to surplus, contingency charges, or risk charges. Assumptions and justifications must be provided by the carrier as follows:

     (a) The methodology, justification, and calculations used to determine the contribution to surplus, contingency charges, or risk charges included in the proposed base rates; and

     (b) The carrier's net worth or reserves and unassigned surplus at the beginning and end of the experience period.

     (4) An actuarially sound estimate of forecasted investment earnings on assets related to claim reserves or other similar liabilities. The carrier must include documentation and justification of forecasted investment earnings identified in dollars, and as a percentage of total premiums and the amount credited to the plans included in the filing.

     (5) Adjustment of the base rate. Experience data, assumptions, justifications, and methodology descriptions must be provided and must include:

     (a) Justifications for adjustments to the base rate, supported by data if appropriate, attributable to geographic region, age, family size, tenure discounts, and wellness activities;

     (b) Justifications, supported by data if appropriate, of any other factors or circumstances used to adjust the base rates; and

     (c) Description of the methodology used to adjust the base rate to obtain the premium rate for a specific individual or group, which is detailed enough to allow the commissioner to replicate the calculation of premium rates if given the necessary data.

     (6) Actuarial certification. Certification by an actuary, as required by RCW 48.44.017(2), 48.44.023(3), 48.46.062(2) and 48.46.066(3).

     (7) The requirements of subsections (1) through (6) of this section may be waived or modified upon the finding by the commissioner that a plan contains or involves unique provisions or circumstances and that the requirements represent an extraordinary administrative burden on the carrier.

[Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200. 05-07-006 (Matter No. R 2004-05), § 284-43-930, filed 3/3/05, effective 4/3/05. Statutory Authority: RCW 48.02.060 and 48.92.140. 98-11-089 (Matter No. R 98-8), § 284-43-930, filed 5/20/98, effective 6/20/98. Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064 and 48.46.066. 98-04-011 (Matter No. R 97-2), § 284-43-930, filed 1/23/98, effective 3/1/98.]

INDIVIDUAL AND SMALL GROUP FILING SUMMARY

Rate Renewal Period:	From		To
Date Submitted:

Proposed Rate Summary

Components of Proposed Community Rate

Summary of Pooled Experience

General Information

Type of Service	Annual Trend Assumed	Portion of Claim Dollars
Hospital	%	%
Professional	%	%
Prescription Drugs	%	%
Dental	%	%
Other	%	%

2.     List the effective date and the rate of increase for all rate changes in the past three rate periods.
1)			2)			3)
	Date	%		Date	%		Date	%
3.     Since the previous filing, have any changes been made to the factors or methodology for adjusting base rates?
Geographic Area			Yes			No
Family Size			Yes			No
Age			Yes			No
Wellness Activities			Yes			No
Other (specify)			Yes			No
4.     Attach a table showing the base rate for each plan affected by this filing.
5.     Attach comments or additional information.
6.     Preparer's Information
Name:
Title:
Telephone Number:

[Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200. 05-07-006 (Matter No. R 2004-05), § 284-43-945, filed 3/3/05, effective 4/3/05. Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064 and 48.46.066. 98-04-011 (Matter No. R 97-2), § 284-43-945, filed 1/23/98, effective 3/1/98.]

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