Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter H - SCHEDULE OF CHARGES
Section 11.703 - Filings and Supporting Documentation
Universal Citation: 28 TX Admin Code § 11.703
Current through Reg. 50, No. 13; March 28, 2025
An HMO must submit schedule of charges information with the certificate of authority application in compliance with § 11.204(11) and (12) of this title (relating to Contents). After the commissioner issues a certificate of authority, the HMO must file rates and supporting documentation before use as follows:
(1) rates for a new product:
(A) evidences of coverage to which the rates
apply;
(B) for individual and small
group plans, a new rate sheet including rates for each plan and each
combination of rating factors used by the HMO; and
(C) actuarial memorandum:
(i) a brief description of benefits and
general marketing method;
(ii) a
brief description of how rates were determined, including a general description
and source of each assumption used;
(iii) a list of retention components,
including, but not limited to, expenses, taxes, fees, and profit expressed as a
percent of premium, dollars per policy, or dollars per unit of
benefit;
(iv) the target loss
ratio, including a brief description of how it was calculated and all
components used in its calculation;
(v) a description of the experience used in
developing the HMO's rates, including the level of credibility and
appropriateness of experience data, and justification for the use of proposed
manual rates if the HMO's own experience is not credible;
(vi) the assumptions and support used in
developing rates, including, but not limited to, adjustments for trend,
morbidity, lapses, risk-mitigating programs, and changes in benefits;
(vii) any other data used to support the
proposed rate; and
(viii) an
actuarial certification required by §
11.702 of this title (relating to
Actuarial Certification);
(2) rate adjustments for an existing product:
(A) evidences of coverage to which the rates
adjustments apply;
(B) for
individual and small group plans, a new rate sheet that includes rates for each
plan and each combination of rating factors used by the HMO; and
(C) actuarial memorandum:
(i) a brief description of benefits and
general marketing method;
(ii) the
scope and reason for the rate revision;
(iii) a description of the experience used in
developing the HMO's rates, including past experience, loss ratio(s) for all
applicable prior experience periods, the level of credibility and
appropriateness of experience data;
(iv) a brief description of how revised rates
were determined, including a general description and source of each assumption
used, which must also include a list of expenses, taxes, fees, and profit,
expressed as a percent of premium, dollars per policy or dollars per unit of
benefit, or both;
(v) the target
loss ratio and description of how it was calculated;
(vi) the assumptions and support used in
developing rates, including, but not limited to, adjustments for trend,
morbidity, lapses, risk-mitigating programs, and changes in benefits;
(vii) any other data used to support the
proposed rate increase; and
(viii)
an actuarial certification required by §
11.702 of this title.
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