Current through Register Vol. 39, No. 6, September 16, 2024
(a) All initial HMO rate filings shall
include, in addition to the data required by
11 NCAC
16 .0603, the following data:
(1) a comparison of the rates to other HMO
rates with the same effective date in North Carolina for similar benefit plans;
and
(2) a three-year financial
projection, provided by the Department's Actuarial Services Division, that
details total membership, revenues, and expenses, and that includes a statement
of cash flow, a balance sheet, and a statement of working capital and net
worth.
(b) All initial
HMO rate filings shall use in the rate development a total retention loading
of:
(1) no greater than 25.0% of the total
premium rate for full-service HMO products issued on a group basis;
(2) no greater than 35.0% of the total
premium rate for single-service HMO products issued on a group basis;
(3) no greater than 35.0% of the total
premium rate for full-service HMO products issued on an individual basis;
or
(4) no greater than 45.0% of the
total premium rate for single-service HMO products issued on an individual
basis.
(c) If an HMO
uses a total retention loading that is less than the maximum limit cited in
Paragraph (b) of this Rule minus 15.0%, then the following supporting
documentation shall be included in the filing:
(1) a listing of each of the specific
components that make up the total retention loading expressed as a percentage
of premium;
(2) a brief description
of the methodology employed to obtain each of the components that make up the
total retention loading;
(3) a
brief explanation as to why any of the components which make up the total
retention loading have changed and a statement of opinion from an officer of
the HMO that these changes are permanent in nature;
(4) a brief, summary description of the
impact of any special fee negotiations or contract arrangements that affect the
premium rates. Identification of specific hospitals or physician groups shall
not be required; and
(5) a
comparison of the rates to other HMO rates with similar benefit
plans.
(d) All HMO's
must project a positive net income after taxes in each of the last 12 months of
the three year financial projection.
Authority
G.S.
58-67-10(d)(1);
58-67-50(b);
58-67-150;
Eff. April
1, 1995;
Readopted Eff. October 1,
2018.
