Current through Register Vol. 46, No. 39, September 25, 2024
The following provisions shall apply with respect to
rates:
(a) General.
(1) Supporting material for all rate filings
shall be separately set forth in an actuarial memorandum or covering letter
accompanying the rates being filed.
(2) All policies, forms, manuals, schedules
and other material submitted shall be in duplicate.
(3) Rate changes, additions and deletions
shall be made by substituting, deleting or adding numbered pages to the rate
manual or schedule of rates.
(4) If
a rate filing precedes the filing of a form, reference should be made to the
rate control number when the form is submitted. Subsequent correspondence
should refer to both control numbers.
(b) Prohibited rating practices.
(1) No rates for any policy shall be
predicated on a level premium age-at-issue basis except:
(i) with respect to conversion policies
issued in accordance with sections 162 and 164 of the Insurance Law;
or
(ii) when the policy form is
guaranteed renewable, is noncancellable or provides that nonrenewal is subject
to the consent of the superintendent. Such consent may be given only with
respect to an entire class of insureds upon request in writing and
determination by the superintendent that such nonrenewal is in the best
interests of the public.
(2) No rates for any policy shall be
predicated upon a reduced initial premium which is less than the pro rata
portion of the applicable annual premium.
(c) Required rate filings for individual
insurance including franchise, blanket insurance, and community-rated contracts
of article 43 corporations. The following rules shall apply with respect to
rates for individual insurance including franchise, blanket insurance, and
community- rated contracts of article 43 corporations:
(1) A rate filing shall accompany every
policy, and rider or endorsement affecting benefits, submitted to the
department for approval. Any subsequent change in rates applicable to any such
policy, rider or endorsement originally delivered or issued for delivery in New
York shall also be submitted to the department. If a rider or endorsement
affects benefits but does not result in a change of rates, a statement of such
fact shall constitute the rate filing.
(2) Every insurer shall file and maintain two
current New York rate manuals in convenient form. The active rate manual shall
include rates for policy forms currently available and being actively marketed.
The inactive rate manual shall include the currently applicable rates on policy
forms no longer available or being actively marketed, where such rates have
been approved or filed subsequent to the effective date of this Part. Each
manual shall include the following:
(i) name
of the insurer on each page;
(ii)
index in alpha-numeric form number order;
(iii) identification by form number of each
policy, rider or endorsement to which the rates apply, and a list of riders and
endorsements which can be attached;
(iv) the schedule of rates, including, if
any, policy fees, rate changes at renewal, variations based upon age, sex,
occupation or other classification, separate charges for optional or
miscellaneous benefits, and if rates are graded by age, a statement of whether
the rates are level based on age-at-issue or attained age at time of
renewal;
(v) an outline of the
essential benefits, coverages, limitations, exclusions, renewal conditions,
limits of the related policy forms, and the expected benefit ratio, defined in
section 52.54(b) of this
Part, which will be used under section
52.44 of this Part in the
monitoring of actual loss ratios;
(vi) an outline of the general rules
pertaining to underwriting limitations with respect to age, amounts and
classifications of eligible risks and, in the case of a rider or endorsement, a
complete list of the policy forms with which it will be used;
(vii) an outline of the general underwriting
rules and methods of marketing the policy form, including, with respect to
article 43 corporations, a rule providing that no community-rated contract may
be issued to a group whose experience under a group insurance policy with any
insurer, including such article 43 corporation indicates a rate in excess of
the then current community rate; however, this rule does not apply to a group
which does not have a sufficient number of employees or members to qualify,
under the article 43 corporation's underwriting rules, for experience
rating;
(viii) an occupational
classification section or separate manual; and
(ix) the additional premium for impaired
risks on a specified impairment or class basis; applicable rate schedules may
be stated in dollar amounts or percentages of the standard premium; if classes
are used, the maximum classification for each impairment shall be set
forth.
(3) Every article
43 corporation shall file and maintain current the schedule of allowances used
in connection with its contract forms.
(d) Rate filings for individual insurance,
including franchise and blanket insurance written by commercial carriers, and
rate filings for community-rated contracts of article 43 corporations and
health maintenance organizations. All rate filings subject to this subdivision
shall include the following:
(1) With respect
to rates accompanying the filing of new policy forms, to the extent
appropriate:
(i) the specific formulas and
assumptions used in calculating gross premiums;
(ii) the expected claim costs;
(iii) identification of morbidity and
mortality tables or experience studies used, sufficient explanation for
evaluation of their validity, including copies of such tables if they are not
currently published;
(iv) the
published data of other insurers;
(v) with respect to article 43 corporations,
percentage breakdown of the rates to show expected claims costs, expenses,
contributions to statutory reserves and surplus;
(vi) the range of commission rates and other
fees payable to agents, brokers, salesmen or other persons except regularly
salaried employees, stated separately for new and renewal business;
(vii) identification of specific rate manual
pages being submitted or already on file applicable to each form and any pages
being replaced or withdrawn;
(viii)
identification of any occupational classification manual being submitted or
already on file applicable to each form;
(ix) the expected future loss ratio, the loss
ratio which will be monitored under section
52.44 of this Part, and the
related minimum under section
52.45 of this Part. The expected
future loss ratio may recognize expected future dividends beyond the second
policy year as benefits, provided modifications are made in the applicable
minimum loss ratio, as described in section
52.45(e) of this
Part. Such dividends may be recognized as an offset to expected premiums
without such modifications to the applicable minimums. Dividends expected to be
paid within the first two policy years may be recognized if the company agrees
not to change the dividend scale until two years from first issue;
(x) the expected loss ratio by policy
duration, where policy years three and later may be combined;
(xi) demonstration of compliance with the
gross premium differential limitations as described in section
52.41 of this Part; and
(xii) methods and assumptions to be used in
approximating earned premiums by duration for section
52.43(a)(1)(iii)
of this Part, if exact methods will not be used.
(2) With respect to rate revisions or
additions to previously approved rate filings of commercial carriers to the
extent appropriate:
(i) complete experience
since inception, both yearly and in total, including the most recent calendar
year if the submission is as of May 1st or later. Include written and earned
premiums, dividends incurred, paid and incurred claims, each reserve, and
earned/incurred loss ratios;
(ii)
complete experience, as above, but with premiums adjusted to a single rate
schedule, identifying the schedule, whether experience is nationwide or New
York State only, and the reserve bases for each year;
(iii) if applicable to policies issued prior
to July 1, 1959, the method of compliance with chapters 945 and 946, Laws of
1958 (Metcalf laws);
(iv)
derivation of the proposed revision in detail. This should include
demonstrations, using interest assumptions from the applicable expected future
loss ratio calculations, that:
(a) the
expected future loss ratio, using the experience in subparagraph (ii) of this
paragraph, projected through the period when rates will be effective, is at
least as large as the larger benefit or loss ratio used in disclosure
statements for the form, and that it meets the requirement of section
52.45 of this Part. If expected
dividends are included in the calculation as benefits, then the demonstration
must be that the projected expected future loss ratio be at least as large as
the disclosed loss ratio when modified by section
52.45(e) of this
Part;
(b) the expected lifetime
loss ratio is at least as large as the disclosed loss ratio. This demonstration
may use future dividends as in (a) and past dividends as benefits. If no policy
was issued subsequent to the effective date of the ninth amendment to this
regulation, no modification in accordance with section
52.45(e) is
necessary. Otherwise, such modifications are necessary;
(c) for policies issued prior to January 1,
1983, the minimum anticipated loss ratio applicable to the policy at time of
issue is to be used in place of the disclosed loss ratio referred to in clauses
(a) and (b) of this subparagraph;
(v) description, in detail, of policy
benefits;
(vi) complete history of
previous rate revisions;
(vii)
first and last years of policy issue and date of original form
approval;
(viii) expected future
loss ratio, expected lifetime loss ratio, and expected loss ratios by duration,
as of the date of filing and as originally filed, and the basis of each. If no
such loss ratios have been filed, the anticipated loss ratio as originally
filed;
(ix) a statement that the
rates approved by the superintendent will be applied to all policies originally
delivered or issued for delivery in New York, regardless of place of current
residence;
(x) the accumulated
value of each item in subparagraph (i) of this paragraph, except for reserves,
such accumulation being made from the midpoint of each calendar year to
December 31st of the most recent year for which data is submitted. Such
accumulation shall employ the interest assumptions used in the applicable
expected future loss ratio calculation, and shall be used in the demonstration
required by subparagraph (iv) of this paragraph;
(xi) when a requested rate revision has been
accepted for approval, revised rate manual pages reflecting the revision. If
the revision is expressed as a percentage of existing rates, and the rates are
part of the inactive rate manual, the insurer may file a single "multiplier"
manual page duly referenced in the table of contents, which reflects the
approved percentage revision to be applied to the manual pages which follow in
lieu of a complete set of revised rate manual pages.
(3) With respect to applications for
revisions of previously approved rates of article 43 corporations and health
maintenance organizations:
(i) information
with respect to claim or utilization frequencies, claim costs and expenses
shown for all contracts and riders, or for each coverage separately if more
than one coverage is provided by a contract or rider, for a period of at least
two years prior to the calendar year in which the new rates are effective, even
though rates for some contracts, riders or coverages are not being
changed;
(ii) the information
required in subparagraph (i) of this paragraph projected for a period not more
than two years beyond the effective date of the new rates;
(iii) a summary of projected changes in claim
or utilization frequency, average claim costs and expenses;
(iv) the current financial condition of the
corporation and the financial condition projected to the effective date of the
new rates and to the end of the period during which the new rates will be in
effect;
(v) the projected operating
results for the period during which the new rates will be in effect, showing
premiums, claims and expenses;
(vi)
such additional information as may be needed in order to assist the
superintendent in determining whether the application shall become effective as
filed, shall become effective as modified, or shall be disapproved;
(vii) as respects rate adjustment
applications where such adjustment is only requested to reflect anticipated
payments to or from the demographic or specified medical condition pooling
funds, such applications shall contain such information as may be needed in
order to assist the superintendent in determining the amount of the adjustment
which is necessary in order to recognize such payments. Such information shall
be in lieu of the material requested in subparagraphs (i), (ii), (iii) and (vi)
of this paragraph; and
(viii) a
jurat subscribed to by the corporation's president or chief executive officer,
treasurer or chief financial officer, and chief actuary or, if the corporation
has no chief actuary, the person responsible for preparing this rate
application. All testimony of the corporation's directors, employees, agents or
representatives made at any public hearing ordered by the superintendent with
respect to the terms of this application shall be subscribed to under oath. The
form of this jurat shall be as follows: (Note: Modify jurat if any of these
persons are not in the employment of the insurer or HMO.)
(insert name), president (or chief executive officer),
(insert name), treasurer (or chief financial officer), (insert name),
chief actuary (or person responsible for preparing this
application), of the (name of insurer or HMO) being duly sworn, each deposes
and says that they are the above described employees of the said insurer or HMO
and hereby affirm that the information in this premium rate application
including all schedules and exhibits thereto has been prepared in accordance
with the applicable provisions of Parts 52, 360 and 361 of Title
11 of the Official Compilation of Codes, Rules and
Regulations of the State of New York
(Regulations 62, 145 and 146) and the most recent
instructions of the New York State
Insurance Department and to the best of their knowledge and
belief is accurate and complete.
________, ________, ________
President Treasurer Chief Actuary
Subscribed and sworn to before me this day of
(e) Required
rate filings for group insurance including master group contracts of article 43
corporations. The following rules shall apply with respect to rates for group
insurance including master group contracts of article 43 corporations:
(1) A rate filing shall accompany every
policy, and rider or endorsement affecting benefits submitted to the department
for approval unless schedules of rates or formulas applicable to such forms
have been previously filed, in which case the rates shall be identified by
reference to specific page number(s) of the manual, formulas or schedules on
file. If the filing contains rate manual pages, the requirements contained in
paragraph (2) of this subdivision for group rate manual submissions must be
satisfied.
(2) Group rate manual
submissions.
(i) Every insurer shall file and
maintain current a schedule of manual rates or formulas which, to the extent
applicable, shall include the following:
(a)
the name of insurer on each page;
(b) table of contents;
(c) an outline of the essential benefits,
coverages, limitations and exclusions to which the rate applies;
(d) a schedule of the premium rates, rules
and classification of risks including any loading for age, sex and
industry;
(e) a definition of
single risk for purpose of size discounts;
(f) a definition and schedule of premium
discounts for self-administration or self- accounting;
(g) the manner of computation and instruction
for interpolating and extrapolating rates; and
(h) a schedule of commissions and
fees.
(ii) The
submission of rate manual pages should include the following information
separate from the rate manual pages:
(a)
specific reference to sections, pages and edition dates of rates submitted,
deleted or revised; and
(b)
justification of rates being submitted or revised, including reference to
relevant information used in the development of such justification and a
demonstration that the applicable minimum loss ratio of section
52.45 of this Part will be
met.
(3)
Filings of forms on a one-case basis shall include the following information:
(i) insurer's name;
(ii) name and location of
policyholder;
(iii) form number if
a policy or, if a rider, the policy form number to which the rider is
attached;
(iv) an outline of the
essential benefits, coverages, limitations and exclusions to which the rate
applies;
(v) if rates are derived
from or contained in the group rate manual, the specific page number(s) where
the applicable rates are found and the actual rates being used;
(vi) if rates for the form are neither
derived from nor contained in the group rate manual, the actual rate being
used, the nature and extent of any deviation from the manual rate and
justification for such deviation; and
(vii) a statement of consistency with filed
rates.
(4) Every article
43 corporation shall file and maintain current the schedule of allowances used
in connection with its contract forms.
(f) Experience-rated group insurance of
insurers other than article 43 corporations. The following rules shall apply to
the readjustment of the rate of premium for those policies rated in accordance
with subsections (g), (h) and (j) of section
4235 of the
Insurance Law.
(1) Policies may be
experience-rated in accordance with a written plan or formula approved by the
board of directors of the insurer or designee thereof, provided that:
(i) any such plan or formula shall not
unfairly discriminate between groups with similar risk characteristics (other
than claim experience, health status or duration since issue) with respect to
credibility factors, stop-loss limits or other rate fluctuation
controls;
(ii) the subparagraph of
section 4235(c)(1) under which coverage is written or the current availability
of a particular plan of insurance underwritten by the insurer for any such
group are not acceptable risk classification factors under any such plan or
formula, however, age, sex, occupation, location, industry, family composition
and other factors affecting utilization and expense are acceptable risk
classification factors; and
(iii)
any such plan or formula shall not permit the selective nonrenewal of a group
or insured person thereunder solely because of claim experience or health
status.
(2) Except as
provided in paragraph (3) of this subdivision, policies insuring less than 50
persons at the inception of the experience-rating period, excluding dependents,
may be experience-rated in accordance with a plan or formula accepted for
filing by the superintendent, provided that:
(i) any such plan or formula shall not result
in a renewal rate for any group which is more than 50 percent higher than the
rate determined under the insurer's rate manual for new business filed pursuant
to subdivision (e) of this section for a group with similar risk
characteristics, notwithstanding claim experience, health status or duration
since issue. Where a policy form is no longer available or actively marketed,
the percentage change in the maximum rate for each rating period shall not
exceed the percentage change in the new business rate for the same rating
period for the policy form with benefits most nearly comparable to the benefits
under the policy form which is no longer available or actively
marketed;
(ii) any such plan or
formula shall not result in a rate change for any group on renewal which
exceeds the sum of:
(a) the percentage change
in the new business rate for such similar group from the first day of the prior
period to the first day of the new period, adjusted to reflect changes in
coverage or the group's risk characteristics, notwithstanding claim experience,
health status, or duration since issue; and
(b) 15 percent, adjusted pro rata for rating
periods less than one year. Where a policy form is no longer available or
actively marketed, the maximum rate change on renewal shall not exceed the
maximum renewal rate change as described in the previous sentence for the
current actively marketed policy form with benefits most nearly comparable to
the benefits under the policy form which is no longer available or actively
marketed;
(iii) any such
plan or formula shall not permit the use of a group's claims experience, health
status or duration since issue in readjusting the rate of premium until the
number of employee or member life/years of experience equals or exceeds 50 and
shall adjust a group's incurred claims to remove unexpected, nonrecurring,
catastrophic claims; and
(iv) any
such plan or formula shall describe the risk classification factors,
underwriting rules and participation requirements as well as transition rules
applicable to existing groups with significant composition changes or to the
negotiated takeover of one or more classes of policies of another
insurer.
(3) The rate of
premium for policies insuring less than 50 persons at the inception of the
rating period, excluding dependents, shall not be readjusted based upon claim
experience, health status or duration of coverage since issue where:
(i) each person covered must satisfy the
insurer's evidence of insurability requirements when initially eligible for
coverage under the policy; or
(ii)
the group or persons representing such group are not provided with reasonable
written disclosure as part of the solicitation and sales materials, of the
extent to which a group's claims experience, health status or duration since
issue will be used by the insurer to establish or adjust the rate of premium
for such group.
(4)
Experience of a preceding insurer or insurers may be relied on to the extent
such experience is available according to a plan or formula filed with the
department to produce higher or lower rates than those otherwise applicable in
the first policy year.
(5) Any
provision contained in the policy with respect to retrospective rate adjustment
or retention by the insurer shall be based on specific factors used in
retrospective rating formulas or plans filed with the department.
(6) For purposes of this subdivision, the
terms group and policy shall also refer to employers which establish or
participate in groups described in subparagraph (B), (D) or (H) of section
4235
(c)(1) of the Insurance Law and to the
insurance written thereunder which insures the employees of such
employers.
(7) The superintendent
may accept for filing a plan or formula, or an amendment thereof, which does
not comply with one or more of the rules contained in this subdivision upon
satisfactory demonstration that such noncompliance is reasonably related to the
financial condition of the insurer and will not result in rates which are
unreasonable, inequitable or unfair under the circumstances.
(g) Experience-rated group
insurance of article 43 corporations. The following rules shall apply to the
adjustment of the rate of premium based on the experience of any contract of
master group insurance as provided for under section
4305 (a) (b) or
(c) of the Insurance Law:
(1) Contracts of master group insurance may
be experience-rated only in accordance with a formula or plan previously
furnished to the department. Such formula or plan shall include a retention
designed to provide for a contribution to surplus.
(2) Any such plan or formula of experience
rating may include provision for a rate stabilization reserve provided that the
terms under which the rate stabilization reserve is created are included in the
master group contract or separate written agreement previously approved by the
department and which upon termination of the group contract impose an
obligation on the plan in respect to the application of the funds represented
by such reserve.
(3) Experience of
a preceding insurer or insurers may be relied on to the extent available
according to a plan or formula filed with the department to produce higher or
lower rates than those otherwise applicable in the first policy year.
(h) Special rules for rates
applicable to benefits under the disability benefits law. The following rules
shall be applicable with respect to policies providing statutory benefits
pursuant to article IX of the Workers' Compensation Law:
(1) Rate schedules for groups of 50 or more
insured persons shall be based on a premium for each $10 of weekly benefit or a
percentage of weekly payroll. Such weekly payroll shall be limited to two times
the maximum weekly disability benefits law benefit per employee.
(2) For groups of less than 50 insured
persons, a simplified rate structure such as monthly per capita rates may be
used.
(i) Special rules
for franchise insurance rates. The following rules shall apply to rates for
franchise insurance:
(1) Rates shall not
unfairly discriminate between cases of the same class. Rates may recognize age,
sex, occupation, location, industry, marital status, family composition and
other factors affecting utilization.
(2) With respect to employee-employer
franchise, rates shall be self-supporting and reasonably related to the
mortality and morbidity assumptions used by the insurer for group insurance,
except where it is demonstrated to the satisfaction of the superintendent that
some other basis is appropriate.
(3) With respect to association or union
franchise:
(i) Rates shall be self-supporting
and shall be reasonably related to the mortality and morbidity assumptions used
by the insurer for individual insurance, except where it is demonstrated to the
satisfaction of the superintendent that some other basis is appropriate. Rates
may differ from those used for comparable individual accident and health
insurance if it is shown to the satisfaction of the superintendent that any
difference results from demonstrable savings in marketing, underwriting, policy
issue and administrative expenses. If no comparable plan of individual
insurance is filed or approved for the insurer, rates used by the insurer for
comparable group insurance shall be deemed to be self-supporting if it is shown
to the satisfaction of the superintendent that marketing, underwriting, policy
issue, administrative, mortality and morbidity costs will not exceed those for
such group insurance.
(ii)
Franchise cases may be experience-rated on the basis of an equitable plan or
formula approved by the superintendent applicable to all franchise cases of the
same class.
(j) Group commissions, compensations, fees
and allowances. Schedules of rates of commissions, compensation, fees and
allowances required to be filed under section
4235
(h) of the Insurance Law shall be filed as
part of the group rate manual and shall contain at least the following
information:
(1) the basis upon which such
schedules apply (e.g., a percentage of the annual premium, a dollar amount per
certificate, or a dollar amount per $100 of weekly indemnity);
(2) if applicable to premiums, the premiums
to which they apply (e.g., monthly, annual, first year or renewal);
(3) any variations in the application of such
schedules based on policy years, alternative scales, grading, type of coverage,
category of agent, territories or any other variable including a clear
explanation of the variable;
(4) if
based on administrative services, the nature of the services and the allowances
therefor; and
(5) the applicability
of any revisions and identification of pages being added, deleted or
substituted.
(k) Special
rules for the submission of rates and supporting documentation applicable to
individual and group Medicare supplement policies. The following rules shall be
applicable in addition to the other requirements of this section.
(1) All filings of rates and rating schedules
shall demonstrate that expected claims in relation to premiums comply with the
requirements of section
52.45(i) of this
Part when combined with actual experience to date. Filings of rate revisions
shall identify the number of persons insured under the New York issued policies
or certificates for which revision is requested and shall also demonstrate that
the anticipated loss ratio over the entire future period for which the revised
rates are computed to provide coverage can be expected to meet the appropriate
loss ratio standards.
(2) An issuer
of Medicare supplement policies and certificates issued before or after May 1,
1992 in this State shall file annually with the submission required in
paragraph (3) of this subdivision its rates, rating schedule and supporting
documentation including ratios of incurred losses to earned premiums by policy
duration for approval by the superintendent in accordance with the filing
requirements and procedures prescribed by the superintendent. The supporting
documentation shall also demonstrate in accordance with actuarial standards of
practice using reasonable assumptions that the appropriate loss ratio standards
can be expected to be met over the entire period for which rates are computed.
Such demonstration shall exclude active life reserves. An expected third-year
loss ratio which is greater than or equal to the applicable percentage shall be
demonstrated for policies and certificates in force less than three
years.
(3) As soon as practicable,
but prior to the effective date of enhancements in Medicare benefits, every
issuer of Medicare supplement policies or certificates in this State shall file
with the superintendent, in accordance with the applicable filing procedures of
this State:
(i) appropriate premium
adjustments necessary to produce loss ratios as anticipated for the current
premium for the applicable policies or certificates. Such supporting documents
as necessary to justify the adjustment shall accompany the filing;
and
(ii) an issuer shall make such
premium adjustments as necessary to produce an expected loss ratio under such
policy or certificate as will conform with minimum loss ratio standards for
Medicare supplement policies and which are expected to result in a loss ratio
at least as great as that originally anticipated in the rates used to produce
current premiums by the issuer for such Medicare supplement policies or
certificates.
(4) Except
for nonprofit health service, hospital service or medical expense indemnity
corporations, no premium adjustment which would modify the loss ratio
experience under the policy other than the adjustments described in paragraph
(3) of this subdivision shall be made with respect to the policy at any time
other than upon its renewal date or anniversary date, as may be approved by the
superintendent.
(5) The
superintendent may conduct a public hearing to gather information concerning a
request by an issuer for an increase in a rate for a policy form or certificate
form issued before or after May 1, 1996 if the experience of the form for the
previous reporting period is not in compliance with the applicable loss ratio
standard. The determination of compliance is made without consideration of any
refund or credit for the reporting period. Public notice of the hearing shall
be furnished in a manner deemed appropriate by the superintendent.
(6) A community rating methodology must be
applied to all policies and certificates of Medicare supplement insurance.
Community rating means a rating methodology in which the premium for all
persons covered by a policy or contract form is the same based on the
experience of the entire pool of risks covered by that policy or contract form
without regard to age, sex, health status or occupation. Refunds, rebates,
credits or dividends based on such factors are also prohibited.