12 a Provide a description by plan for the non-essential health benefits (EHBs) used for pricing and rate development. See Section I, Table 2 below. b Rate impact PMPM for each non-EHB. See Section I, Table 2 below. 13 a Per WAC 284-43-5640(4)(a)(vii), voluntary termination of pregnancy may be included in an issuer's essential health benefits package, but nothing in this section requires an issuer to offer the benefit, consistent with 42 U.S.C. 18023 (b)(1)(A)(i) and 45 CFR. 156.115. This means that issuers are not required to cover voluntary abortion services. However, if issuers decide to cover voluntary abortion services, the abortion services will be part of essential health benefits. In addition, 45 CFR §156.280(e)(4) sets certain requirements for pricing termination of pregnancy. Provide the following questions related to termination of pregnancy. For each plan listed in the rate filing, indicate whether voluntary termination of pregnancy is a covered service. See Section I, Table 2 below. b If voluntary termination of pregnancy is covered, indicate the pricing per member per month (PMPM). See 45 CFR §156.280(e)(4). See Section I, Table 2 below. c Explain in detail that Part I Unified Rate Review Template (URRT) Worksheet 2 is entered appropriately in terms of termination of pregnancy for each plan. See URRT Instructions.
25 For each plan, explain in detail and provide justification whether the premium rate for the plan varies from the market wide rate for the following factors: The actuarial value (AV) and cost-sharing design of the plan. The plan’s provider network and delivery system characteristics, and utilization management practices. Plan benefits in addition to the essential health benefits. Administrative costs, excluding Exchange user fees. You must also provide a table that summarizes the above factors for each plan, and show the projected membership by plan and the weighted average factors for the risk pool. 26 For each plan that is a renewal plan in 2019, provide a table that summarizes the items listed above (#25) in your 2019 filing and in the 2018 filing. For a change to any factor, explain the reason for the change and documentation of the proposed 2019 value. In particular, for a change to each network factor, explain in detail how the previous factor was established noting what network is represented by a factor of 1.000 and whether the network factors reflect efficiency, fee schedule, fee for service or bundled payments, whether the factors are derived using projected 2019 data or current/historical data. Please state the adjustment made to URRT Section II to show the impact of the networks compared to the experience period. State whether the company’s provider compensation includes bonuses in addition to other payments. If it does, explain how the anticipated payment was determined and where in URRT it has been included.
a Include an illustrative example as a separate document in the Rate/Rule Schedule tab and name the file “Illustrative Example for Composite Rating.” You must show how you calculate a two-tiered only composite premium structure for a small employer and satisfy the following requirements: The composite premium for covered adults age 21 and is the average enrollee premium amount calculated at the beginning of the plan year for covered adults age 21 and older, regardless of whether they are an employee or adult dependent. The composite premium for covered individuals under age 21 is simply the average enrollee premium amount for covered individuals under age 21. The premium for a family composition is determined by summing the average enrollee premium amount applicable to each family member covered under the plan, taking into account no more than three covered children under age 21. The average enrollee premium amount calculated for any individual covered under the plan does not include any rating variation for tobacco use (Under Federal rule, for small group plans, tobacco use factor must be tied to wellness activities defined in Federal rule). The rating variation for tobacco use is determined based on the premium rate that would be applied on a per-member basis with respect to an individual who uses tobacco and then included in the premium charged for that individual. If a composite premium is chosen by a small employer, an average enrollee premium amount calculated based on applicable enrollment of participants and beneficiaries at the beginning of the plan year does not vary during the plan year with respect to a particular plan, even if the composition of the group changes. The issuer would recalculate the average enrollee premium amount for the group only upon renewal. b Provide the form filing tracking number, document name, and the language that meet the requirements stated above.