Carrier Name | |
Address | |
Carrier Identification Number | |
Rate Renewal Period: | From | To | ||
Date Submitted: | ||||
Current community rate | per month |
Proposed community rate | per month |
Percentage change | % |
Portion of carrier's total enrollment affected | % |
Portion of carrier's total premium revenue affected | % |
Dollars Per Month | % of Total | |
a) Claims | ||
b) Expenses | ||
c) Contribution to surplus, contingency charges, or risk charges | ||
d) Investment earnings | ||
e) Total (a + b + c - d) |
Experience Period | First Prior Period | Second Prior Period | |
From To | From To | From To | |
Member Months | |||
Earned Premium | |||
Paid Claims | |||
Beginning Claim Reserve | |||
Ending Claim Reserve | |||
Incurred Claims | |||
Expenses | |||
Gain/Loss | |||
Loss Ratio Percentage |
1. Trend Factor Summary |
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: | ||||||||