Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 66.00 - Small Group Health Insurance › Section 66.08 - Submission and Review of Rate Filings

Current through Register 1525, July 5, 2024
(1)
Definitions
. For rate filings submitted pursuant to
			 211
			 CMR 66.08(2), the following
			 definitions also shall apply:
(a)
Adjusted Minimum Medical Loss Ratio
. A specific
			 Carrier's aggregated medical loss ratio for all its merged market plans which
			 was less than the Minimum Medical Loss ratio, but at least 1% greater than the
			 Carrier's equivalent loss ratio for the 12 months prior to the Carrier's
			 present rate filing.
(b)
Capital Costs and Depreciation Expenses
. All expenses
			 associated with depreciation (depreciation for electronic data processing,
			 equipment, software, and occupancy); capital acquisitions (acquisition of
			 capital assets, including lease payments that were paid or incurred during the
			 year); capital costs on behalf of a hospital or clinic (expenditures for
			 capital and lease payments incurred or paid during the year on behalf of a
			 hospital or clinic (or part of a partnership, joint venture, integration or
			 affiliation agreement); and other capital (other costs that are directly
			 associated with the incurring of capital costs, such as legal or administrative
			 costs, incurred or paid during the year).
(c)
Charitable Contributions
			 Expenses
. All contributions to tax-exempt foundations and
			 charities, not related to the company business enterprises.
(d)
Claim Completion
			 Method
. Any actuarial method used to quantify claims which have
			 been incurred but not yet paid.
(e)
Claims Operations Expenses
. All expenses associated
			 with claims adjudication and adjustment of claims, appeals, claims settlement,
			 coordination of benefits processing, maintenance of the claims system, printing
			 of claims forms, claim audit function, electronic data interchange expenses
			 associated with claims processing and fraud investigation.
(f)
Distribution
			 Expenses
. All expenses associated with distribution and sale of
			 products, including commissions, producer, broker and benefit consultant fees,
			 other fees, commission processing and account reporting to brokers, agents and
			 producers.
(g)
Financial Administration Expenses
. All expenses
			 associated with underwriting, auditing, actuarial, financial analysis,
			 investment-related expenses (not included elsewhere), treasury, and
			 reinsurance.
(h)
General Administration Expenses
. All expenses
			 associated with payroll administration expenses and payroll taxes (salaries,
			 benefits and payroll taxes); real estate expenses (company building and other
			 taxes and expenses of owned real estate, excluding home office employee
			 expenses and rent (not allocated elsewhere) and insurance on real estate);
			 regulatory compliance and government relations (federal and state reporting,
			 rate filing, state and federal audits, tax accounting, lobbying, licensing and
			 filing fees, preparation and filing of financial, utilization, statistical and
			 quality reports and administration of government programs); board, bureau or
			 association fees (Board of Directors, Bureau and association fees paid or
			 expensed during the calendar year); other administration (information
			 technology, senior management, outsourcing (not allocated elsewhere), insurance
			 except on real estate, equipment rental, travel (not allocated elsewhere),
			 certification and accreditation fees, legal fees and expenses before
			 administrative and legal bodies, and other general administrative expenses);
			 and negative adjustment for reimbursement from uninsured plans (all revenue
			 receipts from uninsured plans (including excess pharmaceutical rebates and
			 administrative fees net of expenses) and reimbursements from fiscal
			 intermediaries including administrative fees net of expenses from the
			 government).
(i)
Marketing and Sales Expenses
. All expenses associated
			 with billing and Member enrollment (group and individual billing, Member
			 enrollment, premium collection and reconciliation functions); customer service
			 and Member relations (individual, group or provider support relating to
			 membership, enrollment, grievance resolution, specialized phone services and
			 equipment, consumer services and consumer information); product management,
			 marketing and sales (management and marketing of current products, including
			 product promotion and advertising, marketing materials, changes or additions to
			 current products, sales, pricing and enrollee education regarding coverage
			 prior to the sale); and product development: (product design and development
			 for new products not currently offered, major systems development associated
			 with the new products and integrated system network development).
(j)
Medical Administration
			 Expenses
. All expenses associated with quality assurance and cost
			 containment (health and disease management and wellness initiatives (other than
			 for education), health care quality assurance, appeals, case management, fraud
			 detection and prevention, utilization review, practice protocol development,
			 peer review, outcomes analysis related to existing products, nurse triage,
			 medical management and other Medical Care evaluation activities); wellness and
			 health education (wellness and health promotion, disease prevention, Member
			 education and materials, provide education and outreach services); and medical
			 research (outcomes research, medical research programs and development of new
			 medical management programs not currently offered, major systems development
			 and integrated system network development).
(k)
Minimum Medical Loss
			 Ratio
. The Minimum Medical Loss Ratio for the Merged Market is
			 88%.
(l)
Miscellaneous
			 Expenditures Expenses
. All other not classified expenses including
			 all collection and bank service charges, printing, office supplies, postage and
			 telephone (not allocated elsewhere).
(m)
Network Operations
			 Expenses
. All expenses associated with provider contracting
			 negotiation and preparation, monitoring of provider compliance, field training
			 with providers, provider communication materials and bulletins, administration
			 of provider capitation and settlements, hospital and physician relations,
			 medical policy procedures, network access fees and credentialing.
(n)
Normalized per Member per
			 Month Claim Cost
. Claim cost expressed per Member per month
			 adjusted to represent a Member whose rating factors equal one.
(o)
Taxes, Assessments and Fines
			 Paid to Federal, State or Local Governments (as Expenses)
. All
			 expenses associated with taxes (state premium taxes, state and local insurance
			 taxes, federal taxes, except taxes on capital gains, state income tax, state
			 sales tax and other sales taxes not included with the cost of goods purchased);
			 assessments, fees and other amounts paid to regulatory agencies (assessments,
			 fees or other amounts paid to state or local government and does not include
			 taxes or fines or penalties paid to any government agency); and fines and
			 penalties paid to regulatory agencies (penalties and fines paid to government
			 agencies).