Current through Register 1531, September 27, 2024
(1) All base rates
are subject to the Commissioner's disapproval if they do not meet the
requirements of M.G.L. c. 176G, § 16.
(2)
Small Group Base
Rates. Small group and individual base rates shall be submitted in
accordance with M.G.L. c. 176J and
211
CMR 66.00: Small Group Health
Insurance.
(3)
Large Group Base Rates. Each HMO shall submit proposed
large group base rates for each product at least 90 days prior to their
effective date(s).
(4) The
Commissioner shall notify the HMO if he or she determines that the HMO's
submission is not complete and he or she shall identify the manner in which the
submission is not complete. A submission shall not be deemed complete unless it
contains: an actuarial opinion stating that the rates are neither excessive,
inadequate, nor unfairly discriminatory, and that they are reasonable in
comparison to the benefits offered; and any other information required by the
Commissioner. As used in 211 CMR 43.07, "actuarial opinion" means a signed
written statement by a member of the American Academy of Actuaries based upon
the person's review of the appropriate records and of the actuarial assumptions
and methods utilized by the HMO in establishing premium rates for applicable
health benefit plans. The actuarial opinion also shall explain the method in
which the submitted base rates were derived.
(5) An HMO's submission shall contain the
following documentation:
(a) Three years of
historic claims payment experience, including member months, shown separately
for each year and differentiating among:
1.
Inpatient hospital care;
2.
Outpatient hospital care, with separate experience for:
a. Radiological/laboratory/pathology costs;
and
b. All other outpatient
costs;
3. Health care
provider charges for:
a. Medical and
osteopathic physicians;
b. Mental
health providers; and
c. All other
health care practitioners.
4. Supplies; and
5. Outpatient prescription drugs.
(b) Three years of historic
utilization experience, including member months, shown separately for each year
and differentiating among:
1. Inpatient
hospital care;
2. Outpatient
hospital care, with separate experience for:
a. Radiological/laboratory/pathology costs;
and
b. All other outpatient
costs;
3. Health care
provider charges for:
a. Medical and
osteopathic physicians;
b. Mental
health providers; and
c. All other
health care practitioners.
4. Supplies; and
5. Outpatient prescription drugs.
(c) Trend factors differentiating
among:
1. Inpatient hospital care;
2. Outpatient hospital care, with separate
experience for:
a.
Radiological/laboratory/pathology costs; and
b. All other outpatient costs;
3. Health care provider charges
for:
a. Medical and osteopathic
physicians;
b. Mental health
providers; and
c. All other health
care practitioners.
4.
Supplies; and
5. Outpatient
prescription drugs.
(d)
The actuarial basis for all trend factors, including all relevant studies used
to derive the factors;
(e) All
non-fee-for-service payments to providers, differentiating among:
1. Inpatient hospital care;
2. Outpatient hospital care, with separate
experience for:
a.
Radiological/laboratory/pathology costs; and
b. All other outpatient costs;
3. Health care provider charges
for:
a. Medical and osteopathic
physicians;
b. Mental health
providers; and
c. All other health
care practitioners.
4.
Supplies; and
5. Outpatient
prescription drugs.
(f)
Administrative expense load factors, including an explanation of all changes to
any administrative expense loads that were used in the prior period's base
rates and where changes in administrative expenses may be caused by regulatory
requirements or efforts to contain health care delivery costs;
(g) Contribution-to-surplus load factors,
including an explanation of all changes to the contribution-to-surplus load
factor that are caused by regulatory requirements or other external
events;
(h) The anticipated loss
ratios for the one year period during which the proposed base rates will be in
effect;
(i) A detailed description
of all cost containment programs of the HMO to address health care delivery
costs and the realized past savings and projected savings from all such
programs;
(j) If the HMO intends
to pay similarly situated providers different rates of reimbursement, a
detailed description of the bases for the different rates including, but not
limited to:
1. Quality of care
delivered;
2. Mix of
patients;
3. Geographic location at
which care is provided;
4.
Intensity of services provided; and
(k) Three years of historic base rates for
each product.
(6) If the
Commissioner disapproves an HMO's proposed base rate(s), he or she shall notify
the HMO in writing on the effective date of the proposed base rate(s) and he or
she shall state the reason(s) for the disapproval.
(7) Within 30 days of receipt of the
disapproval, the HMO may request a hearing on the disapproval. The hearing
shall be adjudicatory and de novo. The hearing shall commence
within 45 days of the Commissioner's receipt of the HMO's request. The
Commissioner shall issue a written decision within a reasonable period of time
after the conclusion of the hearing.
(8) In the event an HMO's proposed base
rate(s) are disapproved, the HMO shall comply with the following:
(a) The HMO shall not quote, issue, make
effective, deliver or renew health benefit plans in the Commonwealth using
disapproved base rates. The HMO shall instead, if applicable, quote, issue,
make effective, deliver or renew all health benefit plans using base rates as
in effect 12 months prior to the proposed effective date of the disapproved
base rates. 211 CMR 43.07(6)(a) also applies to new health benefit plans whose
base rates are disapproved. In calculating premiums, the HMO may apply any
applicable, but not previously disapproved, base rate adjustment
factors.
(b) The HMO shall
recalculate applicable rates for all affected health benefit plans and shall
issue rate quotes and make all health benefit plans available through all
applicable distribution channels, including intermediaries, the Commonwealth
Health Insurance Connector Authority, licensed insurance producers and the
HMO's website, in accordance with M.G.L. c. 176J and
211
CMR 66.00 as soon as practicable, but in no event more
than ten calendar days after the HMO's receipt of the disapproval.
(c) The HMO shall notify all affected
policyholders of the disapproval within ten calendar days of the HMO's receipt
of the disapproval.
(d) The HMO
shall promptly provide notice of all material changes to the evidence(s) of
coverage to all affected individuals and groups in accordance with M.G.L. c.
176O, § 6(a) and
211 CMR 52.00:
Managed Care Consumer Protections and Accreditation of
Carriers.
