Current through Register 1531, September 27, 2024
(1)
Amended Filing.
A Carrier that is notified that its Rate Filing for a Closed Guaranteed Issue
Health Plan is subject to further review may, no later than 21 days following
that notice, submit an amended Rate Filing in which its rates for that plan
have been reduced by an amount to cause its Adjusted Composite Rate to be less
than the Average Adjusted Composite Rate plus two Standard Deviations. The
Carrier's amended Rate Filing shall then be reviewed in accordance with the
standards in
211 CMR 41.00.
(2)
Carrier's Submission of
Additional Evidence. If a Carrier that is notified that its Rate
Filing for a Closed Guaranteed Issue Health Plan is subject to further review
does not submit an amended Rate Filing, such Carrier may, no later than 21 days
following that notice, submit additional evidence, including an Actuarial
Opinion and Memorandum, to show that:
(a) The
rate filed is reasonable in relation to the benefits provided; or
(b) Its Adjusted Composite Rate would not
have exceeded the Average Adjusted Composite Rate for that type of Closed
Guaranteed Issue Health Plan by more than two Standard Deviations if its
Adjusted Composite Rate had been further adjusted for the case mix of persons
insured in that Carrier's Nongroup Health Plans in operation as of August 15,
1996, whom the Carrier anticipates will be covered in its Closed Guaranteed
Issue Health Plan during the period of the proposed rates.
(3)
Commissioner's Request for
Additional Information.
(a) If
the Commissioner requires additional information to make his or her
determination on further review of the Carrier's Closed Guaranteed Issue Health
Plan Rate Filing, the Commissioner shall, no later than 20 days after the
submission of the Carrier's additional evidence, notify the Carrier in writing
of the additional information required.
(b) A Carrier shall furnish the additional
information no later than ten days after receipt of the Commissioner's
notice.
(c) If, following receipt
of the additional information, the Commissioner requires further additional
information to make his or her determination, he or she shall, within ten days,
notify the Carrier in writing of the further additional information
required.
(d) The Commissioner may
continue to request, and the Carrier shall continue to provide, further
additional information according to the timetables established in 211 CMR
41.11(3)(c) until the Commissioner has received sufficient information to make
his or her determination on further review of the Rate Filing.
(4)
Commissioner's
Determination on Further Review. No later than ten days after the
Commissioner's receipt of the last submission further information from the
Carrier on the Rate Filing, he or she shall make a written determination
regarding:
(a) Whether the Adjusted Composite
Rate filed, further adjusted for case mix pursuant to 211 CMR 41.11(2)(b) if
the Carrier so proposes, would not have exceeded the Average Adjusted Composite
Rate for that type of Closed Guaranteed Issue Health Plan by more than two
Standard Deviations; or
(b) In the
case of an Adjusted Composite Rate that exceeds the Average Adjusted Composite
Rate by more than two Standard Deviations either because the rate, although
further adjusted for case mix would still have exceeded the Average Adjusted
Composite Rate for that type of Closed Guaranteed Issue Health Plan by more
than two Standard Deviations or because the Carrier does not propose an
adjustment for case mix, whether the rate filed is reasonable in relation to
the benefits provided.
(5)
Approval of Proposed Rate on
Further Review. If, after completion of the further review, the
Commissioner determines that the Carrier has demonstrated that:
(a) the Adjusted Composite Rate, further
adjusted for case mix, would not have exceeded the Average Adjusted Composite
Rate for that type of Closed Guaranteed Issue Health Plan by more than two
Standard Deviations; or
(b) The
rate is reasonable in relation to the benefits provided;
The Commissioner shall notify the Carrier that the Rate Filing
is approved.
(6)
Disapproval of Proposed Rate on Further Review. If
after completion of the further review, the Commissioner determines that the
Carrier has not demonstrated that:
(a) The
Adjusted Composite Rate, further adjusted for case mix, would not have exceeded
the Average Adjusted Composite Rate for that type of Closed Guaranteed Issue
Health Plan by more than two Standard Deviations; and
(b) The rate filed is reasonable in relation
to the benefits provided;
The Commissioner shall notify the Carrier that the Rate Filing
is disapproved and of the Carrier's right to request a
Proceeding.
