North Carolina Administrative Code
Title 11 - INSURANCE
Chapter 16 - ACTUARIAL SERVICES DIVISION
Section .0600 - HEALTH MAINTENANCE ORGANIZATION FILINGS AND STANDARDS
Section 16 .0607 - HMO INCURRED LOSS RATIO STANDARDS
Universal Citation: 11 NC Admin Code 16 .0607
Current through Register Vol. 39, No. 6, September 16, 2024
(a) The following shall apply to all HMO rate revision filings:
(1) The application of a requested rate
increase or decrease shall result in an average incurred loss ratio projected
for North Carolina over the period required in
11 NCAC
16 .0606(8) of this Section
that is not less than:
(A) 75.0% for
full-service HMO products issued on a group basis;
(B) 65.0% for single-service HMO products
issued on a group basis;
(C) 65.0%
for full-service HMO products issued on an individual basis; or
(D) 55.0% for single-service HMO products
issued on an individual basis.
(2) If the average incurred loss ratio
projected for North Carolina over the period required in
11 NCAC
16 .0606(8) of this Section
is greater than the minimum limit cited in Subparagraph (a)(1) of this Rule
plus 15.0%, then the following supporting documentation shall be included in
the filing:
(A) a list of each of the specific
components that make up the total retention loading expressed as a percentage
of premium;
(B) a brief description
of the methodology employed to obtain each of the components that make up the
total retention loading;
(C) a
brief explanation as to why any of the components that 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;
(D) a brief, summary description of the
impact of all special fee negotiations or contract arrangements that affect the
premium rates. Identification of specific hospitals or physician groups shall
not be required; and
(E) a
comparison of the rates to other HMO rates with similar benefit
plans.
(b) The following shall apply to all initial HMO rate filings and HMO expansion requests:
(1) The average incurred loss ratio
projected for North Carolina over the last 12 months of the three year
financial projection period shall be no less than:
(A) 75.0% for full-service HMO products
issued on a group basis;
(B) 65.0%
for single-service HMO products issued on a group basis;
(C) 65.0% for full-service HMO products
issued on an individual basis; or
(D) 55.0% for single-service HMO products
issued on an individual basis.
(2) If the average incurred loss ratio
projected for North Carolina over the last 12 months of the three year
financial projection is greater than the minimum limit cited in Subparagraph
(b)(1) of this Rule plus 15.0%, then the following supporting documentation
shall be included in the filing:
(A) a list of
each of the specific components that make up the total retention loading
expressed as a percentage of premium;
(B) a brief description of the methodology
employed to obtain each of the components that make up the total retention
loading;
(C) a brief explanation as
to why any of the components that 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;
(D) 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
(E) a
comparison of the rates to other HMO rates with similar benefit
plans.
Authority
G.S.
58-67-50(b);
58-67-150;
Eff. April
1, 1995;
Readopted Eff. October 1,
2018.
Disclaimer: These regulations may not be the most recent version. North Carolina may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
