Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6020 - Definitions

Current through Register Vol. 24-14, July 15, 2024
For the purpose of this subchapter:
(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."