Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter D - OPERATIONAL STANDARDS FOR A HEALTH MAINTENANCE ORGANIZATION › Section 301.63 - Rate approvals

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Rates
				  charged members or groups of members shall be filed with the Commissioner and
				  be deemed approved unless explicitly rejected within 60 days of receipt of the
				  filing by the Department. Disapproval of a rate filing by the Commissioner may
				  be appealed under 2 Pa.C.S. (relating to administrative law and
				  procedure).
(b) Rate filings shall
				  describe the benefit package, identify the class of membership-for example,
				  group, group conversion, nongroup and the like-and indicate the form number of
				  the contract form to which the proposed premium rates will apply.
(c) Rate filings shall indicate the period
				  during which the proposed premium rates will be effective for issues and
				  renewals and the period for which the rates will be contractually
				  guaranteed.
(d) Rate filings shall
				  indicate the effective date of the last rate revision.
(e) Rate filings shall state the percentage
				  by which the proposed rates exceed the current rates.
(f) Rate filings shall describe the procedure
				  and identify the assumptions used to convert the total cost per member per
				  month to the proposed premium rates. This includes the current and proposed
				  assumptions for premium structure-ratio of family premium to single and the
				  like-for distribution of contracts, and for number of members per
				  contract.
(g) Rate filings shall
				  describe the procedure and identify the inflationary trend factors used to
				  project the proposed premiums from the initial rating period to each succeeding
				  rating period.
(h) Rate filings
				  shall list, for every claim component utilized by the HMO constructing the
				  proposed premium rates, the assumed utilization, the average unit cost and the
				  cost per member per month. Assumptions for expenses, profits, incentive
				  margins, specialist and primary care capitations and similar items shall also
				  be defined and listed. The rate filing shall compare in tabular fashion these
				  assumptions with the corresponding assumptions used in calculating the current
				  premium rates and with the actual experience data. The experience period shall
				  be identified. Assumptions and trend factors for the proposed premium rates
				  shall be identified and justified by using the current assumptions and the
				  experience data. The hospital unit component shall be subdivided by
				  hospital.
(i) For contractual
				  capitation arrangements, rate filings shall indicate the effective and
				  termination dates of the current contracts, the current capitation amounts and
				  the proposed capitation amounts for contracts due to be renewed during the
				  rating period. Filings shall identify the premium rate components which in
				  total equal the average capitation amounts paid to providers.
(j) Rate filings shall show the number of
				  contract months and member months exposed during the experience
				  period.
(k) Rate filings shall show
				  the total number of members for the four most recent calendar quarters
				  available and the projected number of members by quarter during the rating
				  period.
(l) Proposed premium rates
				  shall be shown in a table which is separate from the other information in the
				  rate filing.
The provisions of this §
												301.63 amended under sections 206,
						506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						§§
													66,
						186,
						411 and
						412); and the Health
						Maintenance Organization Act (40 P. S. §§
													1551-1567).