Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule prescribes the form and content of
the rate information required to be submitted to the Missouri Department of
Commerce and Insurance and sets forth the standards of review applicable to
such filings.
(1) Scope. This
rule is applicable to rates for health benefit plans that are subject to
section 376.465.7, RSMo.
(2)
Definitions. As used in this rule, the following terms mean:
(A) "Director," means the Director of the
Department of Commerce and Insurance or the director's designee;
(B) "Health benefit plan," means those health
benefit plans described under section 376.465.7, RSMo, and shall include
student health plans;
(C) "Rate,"
means the amount of money a health carrier charges as a condition of providing
coverage under a health benefit plan;
(D) "Rate filing," means a submission through
SERFF that contains rates and rate filing justifications as well as other
documents required by this rule and that assist the director in making
determinations consistent with
45 CFR
154.215 and section 376.465, RSMo;
(E) "Rate filing justification," means
actuarial data and other related information provided by a health carrier that
supports the use of the proposed rate;
(F) "Student health plan," means a type of
health coverage maintained pursuant to an agreement between an institution of
higher education and a health carrier under which coverage is provided in
connection with enrollment as a student at that institution of higher
education, regardless of how the coverage is underwritten or issued;
(G) "System for Electronic Rate and Form
Filing" or "SERFF," means the web-based interface system used for the
submission of rate filings and form filings.
(3) All rates, rate filings, rate filing
justifications, and any communication or notices filed under this rule shall be
submitted through SERFF.
(4) All
rate filings must conform to the requirements of
20 CSR
100-9.100.
(5) All proposed rates and rate filings for
health benefit plans to be delivered, issued for delivery, continued, or
renewed on or after January 1, 2018, shall contain the following:
(A) Rates for each health benefit plan
including all variations based on age, rating area, and tobacco use, in an
Excel spreadsheet, or other format as allowed by the director;
(B) Identification of all policy forms to
which the rate filing will apply, including SERFF tracking number, policy form
number, and plan identification number. A rate filing shall be made separately
and apart from a policy form filing;
(C) The total number of in-force policies or
certificates to which the rate filing will apply;
(D) The rate filing justification as
described in section (6) of this rule; and
(E) Any other data or information that
provides a sufficient basis for the director to determine if the proposed rates
are reasonable and to complete the review under the standards outlined in 45
CFR Part 154.
(6) A
health carrier shall submit a rate filing justification as follows:
(A) Part 1 of the rate filing justification
shall be submitted on a form and in the manner prescribed by
45 CFR
154.215(d). Part 1 shall
include the following data and information:
1. Historical and projected claims
experience;
2. Trend projections
related to utilization and service or unit cost;
3. Any claims assumptions related to benefit
changes;
4. Allocation of the
overall rates to claims and non-claims costs;
5. Per enrollee per month allocation of
current and projected premium; and 6. Three- (3-) year history of rates for the
product associated with the rate filing;
(B) Part 2 of the rate filing justification
shall contain a brief, non-technical, consumer-oriented explanation of the
proposed rates contained in Part 1 and any modifications contained therein.
This explanation shall include a simple and brief narrative describing the
data, information, and assumptions the health carrier used to develop the rate.
Part 2 shall include, but not be limited to, the following:
1. An explanation of the most significant
factors underlying a rate increase or decrease, where applicable, including a
brief description of the relevant claims and non-claims expense increases
reported in Part 1; and 2. A brief description of the overall experience of the
policy, including historical and projected expenses and loss ratios;
(C) Part 3 of the rate
justification shall contain an actuarial memorandum that contains the reasoning
and assumptions supporting the data and information contained in Part 1 of the
rate justification. The actuarial memorandum shall be submitted by a qualified
actuary who represents the health carrier and who is a member of the American
Academy of Actuaries.
1. A health carrier may
submit a public version of Part 3 that redacts properly designated trade
secrets or proprietary information. This redacted document shall be clearly
denoted as the Part 3 Public Version. The health carrier may only redact
information that is trade secret or proprietary under Missouri law. The Part 3
Public Version shall be submitted in SERFF as a document separate from other
rate information.
2. If a health
carrier submits a Part 3 Public Version, the health carrier must also submit an
un-redacted version. This un-redacted version shall contain all of the required
data and information with no redactions. The un-redacted version shall be
clearly denoted as the Part 3 Confidential Version and submitted in SERFF as a
document separate from other rate information.
(7) Any trade secret information included as
a part of the rate filing justification must be designated as such by the
health carrier and shall be subject to the provisions of sections
417.450-417.467, RSMo, and
20 CSR
10-2.400. All data and information contained within a
rate filing or rate filing justification that is not clearly designated as
either trade secret or proprietary under Missouri law, filed under this rule,
will be open to the public.
(8) A
health carrier shall submit rates and rate filing justifications, as outlined
in this rule, to the Centers for Medicare and Medicaid Services on the same
date it submits the information to the director, consistent with the
requirements of 45 CFR Part 154.
(9) The director shall designate annual
filing deadlines and posting dates, not inconsistent with the requirements of
45 CFR Part 154. The designation of annual filing deadlines may be announced
through a bulletin or other electronic means as determined by the
director.
(10) All proposed rates
shall be posted at a uniform time on the department's website. All final rates
shall be posted at a uniform time on the department's website.
(11) The department shall allow the
submission of public comments regarding proposed rates in written form,
submitted to the department by mail or in an electronic format. The comment
period shall be open for at least thirty (30) days from the date the proposed
rates are posted. Comments received on rate filings shall be accessible to the
public through the department's website.
(12) A rate shall be determined to be
unreasonable if the rate is excessive, inadequate, unfairly discriminatory, or
unjustified.
(A) A rate is excessive if it is
unreasonably high for the coverage provided under the health benefit
plan.
(B) A rate is inadequate if
it is unreasonably low for the coverage provided under the health benefit plan
or the use of such rates endangers the solvency of the health carrier using the
rate.
(C) A rate is unfairly
discriminatory when a health carrier makes or permits differences in rates
between individuals of the same class or of essentially the same risk when such
differences are not permissible pursuant to section
375.936,
RSMo, or when differences in rates do not reasonably correspond to differences
in expected costs.
(D) A rate is
unjustified if the heath carrier provides a rate justification that is
incomplete or otherwise does not provide a sufficient basis upon which the
reasonableness of a rate can be determined.
(13) The director's review of rates shall, at
a minimum, consider the following:
(A) The
reasonableness of the assumptions used by the health carrier to develop the
proposed rate increase and the validity of the historical data underlying the
assumptions;
(B) The health
carrier's data related to past projections and actual experience;
(C) The reasonableness of assumptions used by
the health carrier to estimate the rate impact of the federal risk adjustment
program under
42 U.S.C. Section
18063; and
(D) The health carrier's data related to
implementation and ongoing utilization of a market-wide single risk pool,
essential health benefits, actuarial values, and other market standards or
rules established under state or federal law.
(14) The director's review of rates may
consider the following, to the extent the director believes any to be
applicable to the rate filing under review:
(A) Medical cost trend changes by major
service categories;
(B) Impact of
changes in utilization of services by major service categories;
(C) Impact of cost-sharing changes by major
service categories, including actuarial values;
(D) Impact of changes in benefits, including
essential health benefits and non-essential health benefits;
(E) Impact of changes in enrollee risk
profile and pricing, including rating limitations for age and tobacco use under
42 U.S.C. Section
300gg;
(F) Impact of over- and under-estimation of
medical trends in the previous three (3) years on the current premium
rate;
(G) Impact of changes in
reserve needs; (H) Impact of changes in administrative costs related to
programs that improve health care quality;
(I) Impact of changes in other administrative
costs;
(J) Impact of changes in
applicable taxes and licensing or regulatory fees;
(K) Medical loss ratio;
(L) The health carrier's capital and
surplus;
(M) The impacts of
geographic factors and variations;
(N) The impact of changes within a single
risk pool to all products or plans within the risk pool; and
(O) The impact of risk adjustment payments
and charges.
(15)
Pursuant to section 376.465.10(4), RSMo, written notice of the director's
determination that proposed rates are reasonable or unreasonable shall be
provided within sixty (60) days after a complete rate submission to the
director. This sixty- (60-) day time frame may be extended pursuant to a mutual
agreement between the director and the health carrier.
(A) Proposed rates that are determined to be
reasonable will be considered final and the filing will be closed upon the same
date as the director's notice.
(B)
Proposed rates that are determined to be unreasonable will be considered open
for amendment by the carrier pursuant to section (16) of this rule.
(16) Pursuant to section
376.465.11, RSMo, after receiving written notice from the director that a
proposed rate is unreasonable, if a health carrier elects to amend proposed
rates or request reconsideration of the director's determination, the carrier
shall notify the director and submit any amendments or additions to the rate
filing or rate filing justification within thirty (30) days after the date the
carrier receives written notice of the director's determination. The thirty-
(30-) day time frame may be extended pursuant to a mutual agreement between the
director and the health carrier.
(A) If a
health carrier chooses to file an amended rate, it shall file the amended rate
and a rate filing justification supporting the amended rate.
(B) If a health carrier chooses to request
reconsideration, it shall notify the director, in writing, of its request for
reconsideration and may submit any additional rate filing justification that it
believes further supports the proposed rate. The director shall review such
information and make a determination as to whether the proposed rate is
reasonable or unreasonable.
(17) When a health carrier receives written
notice that a proposed rate is unreasonable and the health carrier decides to
implement the proposed rate notwithstanding the director's determination, the
health carrier shall notify the director of its decision to use the rate within
thirty (30) days after receiving notice of the director's determination. The
director shall make the determination that the rate is unreasonable publicly
available on the department's website at the same time as final rates are
posted on the department's website.
*Original authority: 374.045, RSMo 1967, amended
1993, 1995, 2008 and 376.465, RSMo
2016.
