Health Insurance Premium Grants: Detailed State by State Summary of Proposed Activities
On August 16, 2010, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced the award of $46 million to enhance States’ current processes for reviewing health insurance premium increases. Forty-five States and the District of Columbia applied for grants, and each will receive $1 million in grant funds to help improve the review of proposed health insurance premium increases, take action against insurers seeking unreasonable rate hikes, and ensure consumers receive value for their premium dollars. A list of States’ current health insurance rate review practices and a summary of their intended use of these new resources is below.
States have proposed to use this funding in a variety of ways.
- Additional Legislative Authority: 18 States and the District of Columbia will pursue additional legislative authority to create a more robust program for reviewing or requiring advanced approval of proposed health insurance premium increases to ensure that they are justified.
- Expand the Scope of Health Insurance Premium Review: 21 States and the District of Columbia will expand the scope of their current health insurance review, for example by reviewing and pre-approving rate increases for additional health insurance products in their State.
- Improve the Health Insurance Premium Review Process: All 46 State grantees will require insurance companies to report more extensive information through a new, standardized process to better evaluate proposed premium increases and increase transparency across the marketplace.
- Make More Information Publicly Available: 42 States and the District of Columbia will increase the transparency of the health insurance premium review process and provide easy to understand, consumer friendly information to the public about changes to their premiums.
- Develop and Upgrade Technology: All State grantees will develop and upgrade existing technology to streamline data sharing and put information in the hands of consumers more quickly.
The chart below provides a detailed summary of how each State intends to overhaul its health insurance premium review process.
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W
- Current Authority
- Individual Market: Individual: Alabama has limited rate review authority. Blue Cross Blue Shield rates are approved if they do not alter the expense formula (Ala. Code § 10-4-109). HMOs must file rates before use. HMOs and Blue Cross Blue Shield must file actuarial justifications and can use any rating trait. Commercial carriers are encouraged to file rates but do not have any requirement to do so.
- Small Group Market: Small Group Market: HIPAA rating restrictions only (Ala. Admin. Code r. 482-1-116-.01 (2010)).
- Additional Legislative Authority: Currently the department has very limited health insurance premium review authority - restricted to reviewing premiums proposed by Blue Cross Blue Shield and HMOs They will develop legislative language to expand review authority and add approval authority in 2011 session.
- Expand the Scope of Health Insurance Premium Review: The State will expand the scope to include additional health insurance carriers, markets and lines of business.
- Improve the Health Insurance Premium Review Process: With the current limitations in review authority, the State plans significant improvements. The State proposes to develop a new review unit. They will develop and implement regulations as well as establishing a standardized filing and review process.
- Make More Information Publicly Available: The State does not currently publish rate filings that are considered proprietary. They will seek authority to post consumer friendly summaries, develop toolkits for consumers, conduct town hall meetings for consumer education.
Arizona
- Current Authority
- Individual Market: Individual: Initial rates are filed for prior approval (5 percent of total filings). Rate revisions are file and use and screened for completeness. Benefits must be reasonable in relation to the premium charged as defined in AAC R20-6-607. Actuarial certification must comply with the 55 percent loss ratio minimum.
- Small Group Market: Small Group Market: All carriers must file actuarial certification that rates comply with state rating laws. No other filing requirements (A.R.S. § 20-2311). No filing requirements for large groups or HMOs.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Currently Arizona only checks filings in the individual market for completeness. The State intends to improve their filing review process by hiring an actuarial consultant to review 95% of submissions for compliance and make recommendations regarding whether filings are unjustified or excessive.
- Make More Information Publicly Available: Hard copy filings are currently available only upon request, or an individual can go to their office for viewing in the system. Grant funds will be used to create a website for publication of FAQs for consumers as well as consumer friendly rate filings and rate increase justifications.
Arkansas
- Current Authority
- Individual Market: Individual: All rates are subject to the prior approval of the Department (ACA §23-79-109(a)(1)(A)). Actuarial certification must comply with the 50 percent minimum loss ratio.
- Small Group Market: Small Group Market: All carriers must file actuarial certification that rates comply with rating reforms (age and geography) and rate bands (ACA §23-86-204).
- Additional Legislative Authority: Arkansas currently has prior approval over individual market rates. The State will seek authority to review small group rates.
- Expand the Scope of Health Insurance Premium Review: The State intends to expand to review small group rates.
- Improve the Health Insurance Premium Review Process: Currently Arkansas conducts prospective review of individual coverage and intervenes for rate increases above 10%. The State will work with consultants to develop a more thorough review process for filings. New staff will be added to conduct reviews.
- Make More Information Publicly Available: Currently the State discloses approval vs. disapproval via publishing its disposition letters on the web and requires 30 days public notice on rate increases prior to implementation, however no details are published. Using grant funding, they will create and staff a consumer driven Advisory council, to improve transparency and communications to all stakeholders via an expanded website as well as create a Rate Review Center for consumers and issuers.
- Current Authority
- Individual Market: 2 regulators: Department of Managed Health Care (DMHC), and California Insurance Department (CDI). Department of Managed Health Care (DMHC) regulates Knox-Keene Act plans (HMOs, some PPOs). Individual Market: HIPAA PPO products cannot exceed the price of the high-risk pool for comparable coverage. HIPAA HMO products cannot exceed 170 percent of the high-risk pool. HMOs must limit administrative expenses to 15 percent. California Department of Insurance (CDI): All products are subject to review for compliance with 70 percent loss ratio and rating reforms. CDI recently expanded outside actuarial review for the largest carriers.
- Small Group Market: Small Group Market: DMHC: generally, HMOs must file rating methodology to demonstrate compliance with rating reforms. CDI: Carriers are required to file rating plans and filings are reviewed for compliance with statutory case traits and rating reforms.
- Additional Legislative Authority: The governor will present legislation that synchronizes review activities across DMHC and CDI offices.
- Expand the Scope of Health Insurance Premium Review: The State intends to collect and review all individual and small group premiums by the Department of Managed Health Care. Currently this is done by California’s Department of Insurance. Currently, DMHC and CDI regulate different pieces of the health insurance market. DMHC regulates managed care and some PPOs, and CDI regulates the remainder of the market. DMHC has very limited rate review authority and if the legislature grants the new authority, the number of carriers and rates that undergo review would dramatically increase
- Improve the Health Insurance Premium Review Process: DMHC currently has limited review authority. Both agencies will improve the collection of premium rate information, enhance the depth and breadth of current rate review activities, and make IT system improvements. If necessary, legislation will be introduced to support this change. DMHC will initiate actuarial review of filings and CDI will enhance its existing actuarial review capacity.
- Make More Information Publicly Available: Currently only CDI posts filings. DMHC will begin to post filings and both units will provide consumer education.
Colorado
- Current Authority
- Individual Market: Individual: All rate increases require the prior approval of the Department. Zero percent rate increases and new products are file and use.
- Small Group Market: Small Group Market: Same authority as individual market. Carriers may use community rating and rating bands for the case characteristics of age, geographic location, family size and tobacco use as defined in Regulation 4-6-7. Rate filings with at least 80 percent loss ratio are expedited.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Colorado currently prospectively reviews all premium increases. The State will update its existing review and filing requirements to enhance the quality of its review process and comply with all new federal requirements. Contracted actuaries and rate analysts will be used to develop and implement the new process.
- Make More Information Publicly Available: Currently rate filings are not publicly available, but summaries are posted on the web. Colorado will make its website more consumer friendly and will post complete premium increase filings. Additionally, the State will conduct web-based town hall meetings to educate consumers and will host public rate hearings.
Connecticut
- Current Authority
- Individual Market: Individual: All rates (commercial, HMO and Blue Cross Blue Shield) require the prior approval of the Department. Carriers may elect (1 carrier to date) to guarantee a loss ratio with premium refund and avoid prior approval of rates. Current rates typically vary by age, gender, location, and smoking.
- Small Group Market: Small Group Market: HMO rates require the prior approval of the Department. All other rates are file and use. Rates are required to be community rated, but currently may be adjusted for age, gender, geographic location, industry, family composition and group size, but not for health conditions or claims experience. Large Group: Same as small group.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Connecticut currently prospectively reviews all individual and HMO product premium increases. Connecticut will enhance its existing premium review process by developing new in-depth premium filing requirements and by improving its review capacity through new analytic software applications and consultant actuaries. Additionally, the State will conduct comprehensive actuarial review on all rates that are determined to be unreasonable under the ACA.
- Make More Information Publicly Available: Currently premium filings are only available upon request. Connecticut will post premium filings on its website and will provide the public with a comment period.
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. Products must meet minimum loss ratios (reasonableness standard) that range between 50 and 60 percent depending on renewal.
- Small Group Market: Small Group Market: The authority is the same as the individual market. Carriers must provide actuarial certification of compliance with state rating reforms. Traits permitted are: age, industry, geographic area, family composition, unhealthy lifestyle choices and group size.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Delaware currently prospectively reviews all premium increases. Delaware will develop new premium filing requirements and improve its ability to review rates through analytic software, systems enhancement and additional review staff.
- Make More Information Publicly Available: Currently, Delaware only discloses premium filings upon request. The State will post premium filings on its website and make other enhancements including a new rate comparison feature. Additionally, the State will host public meetings and hearings on proposed rate increases.
District of Columbia
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. Blue Cross Blue Shield rates (§31-3508) and HMO rates (§31-3415) shall not be excessive, inadequate, or unfairly discriminatory in relation to the services and benefits offered. Any increase in order-of-magnitude 10% or greater is referred to an executive panel for consideration.
- Small Group Market: Small Group Market: HMO rates require the prior approval of the Department. All other rates are file and use. Blue Cross Blue Shield rates can be disapproved if not in compliance.
- Additional Legislative Authority: The District currently has prior approval authority for rate filings in the individual market and for HMOs. The District will review its existing legal framework and those of other States and will propose changes to the law and regulations that reflect best practices and will make rate filing requirements consistent for all types of issuers and all products.
- Expand the Scope of Health Insurance Premium Review: The District will begin to require all insurers to file rate changes, previously only Blue Cross Blue Shield and HMOs were required to file rates.
- Improve the Health Insurance Premium Review Process: The District currently has prior approval authority for rate filings in the individual market and for HMOs. Using grant funds, they will adopt regulations establishing a template for the information required to be included with a rate filing. They will analyze data from rate filings to identify trends and develop statistical information.
- Make More Information Publicly Available: Currently, information about rate filings is only provided to the public after the filing has been approved and only in response to a FOIA request. The District will develop a web site with consumer-friendly information. It will also do outreach to inform the public about the information that is available and provide the opportunity for input into the rate review process.
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. Policy forms providing similar benefits are pooled for all rating purposes. Case characteristics for individual products must be actuarially justified and non-discriminatory. The minimum loss ratio for guaranteed renewable individual policy forms is 65 percent and can be reduced by as much as 10 percent based on the average annual premium.
- Small Group Market: Small Group Market: Same authority as individual. Case traits include: age, gender, family composition, area by county, tobacco usage, effective date, and trend. Carriers must meet a minimum loss ratio of 65 percent. Large Group: Must meet minimum loss ratio between 65 and 75 percent depending on group size.
- Additional Legislative Authority: Florida currently does not have review and approval authority over large group rates or over policies sold by out-of-State companies to Florida residents. The State will seek approval authority for these products during the 2011 legislative cycle.
- Expand the Scope of Health Insurance Premium Review: The State will expand the scope to include large group and out-of-State products.
- Improve the Health Insurance Premium Review Process: Florida currently prospectively reviews individual and small group premium increases. Florida will enhance its premium review process by implementing new premium filing requirements. Additionally Florida will improve the quality of its review process by hiring additional actuaries and by making improvements to its existing systems.
- Make More Information Publicly Available: Florida currently posts premium increase filings on its website. The State will develop a new search tool to make it easier to access filings.
- Current Authority
- Individual Market: Individual: All products and all rates require the prior approval of the Department (Hawaii Code 431:14-G-103(a)). Rates shall not be excessive, inadequate, or unfairly discriminatory and shall be reasonable in relation to the benefits provided.
- Small Group Market: Small and Large Group: Same authority as individual.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Currently, extensive rate review is done but not well reported. The State intends to use funds to contract for development of smart systems to support rate review activities.
- Make More Information Publicly Available: The DOI will produce consumer-friendly reports on pending and completed rate filings that are accessible on the Internet.
- Current Authority
- Individual Market: Individual: File and Use for all rates. Health plans must file rates annually, along with actuarial certification of compliance with state rating rules. Rates must be reasonable and carriers must adhere to the rating procedures set out in its rate manual and may not modify the rating method used in its manual unless the change is approved by the Department. Case characteristics allowed under Idaho law are age, tobacco use, geography and gender.
- Small Group Market: Small Group Market: Same authority as individual. Large Group: No requirements.
- Additional Legislative Authority: Idaho will hire legal consultants to draft language for submission to the legislature.
- Expand the Scope of Health Insurance Premium Review: Idaho will expand the scope of its review authority to include the large group market.
- Improve the Health Insurance Premium Review Process: Currently, Idaho only requires an insurer to file a health insurance premium adjustment with the State – they do not require insures to get prior approval for increases in health insurance premiums before they go into effect. The State will expand and improve its existing review process, resulting in more premiums being subject to thorough actuarial review. Idaho will standardize and broaden its filing requirements, automate data collection and review processes, and contract with actuaries to conduct in-depth premium reviews.
- Make More Information Publicly Available: State law prohibits the release of filing information. No proposed transparency improvements are planned.
Illinois
- Current Authority
- Individual Market: Individual: No explicit rate review authority. Carriers must file premium rates and “classification of risks” with the Department (215 ILCS 5/355). HMOs must file a schedule of base rates and supporting actuarial documentation.
- Small Group Market: Small Group Market: Same authority as individual. HMOs must file a schedule of base rates and supporting actuarial documentation (50 Ill. Admin. Code 5421.60). No other filing requirements.
- Additional Legislative Authority: Illinois currently does not have explicit rate review authority. The State intends to seek authority to review and approve premium rates and to disclose premium filings.
- Expand the Scope of Health Insurance Premium Review: Illinois will initiate rate review and approval for all forms of major medical coverage.
- Improve the Health Insurance Premium Review Process: Illinois currently does not have explicit rate review authority. Illinois will develop the capacity to conduct prospective actuarial review on all major medical premium increases. The State will develop new rate filing and review protocols. Additionally, new IT systems will be developed and additional staff will be hired in order to conduct premium reviews.
- Make More Information Publicly Available: Premium filings are not currently available to consumers. Illinois will start posting filings. Additionally the State will conduct public hearings on proposed rate increases. It will also develop interactive tools to help users navigate insurance premium information on its website. Illinois will also translate web and print health insurance information into Spanish, Polish and Korean.
Indiana
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. Minimum loss ratios vary between 50 and 60 percent depending on renewal clause (NAIC model). Rates must be reasonable in relation to benefits (IC 27-8-5-1.5).
- Small Group Market: Small Group: HMO rates require the prior approval of the Department (IC 27-13-20-1). All other carriers must file rates with the Department.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Indiana currently prospectively reviews all premium increases. The State will improve the rigor of its current review process by acquiring contracted actuarial support. Additionally the State will conduct a study to identify best review practices across States and identify areas where existing regulations and legislation can be strengthened.
- Make More Information Publicly Available: Rate filings are currently available upon request. The State will develop a consumer website that will provide complete rate filings and high -level filing summaries. Consumers will be able to post comments on proposed rate increase directly on the site.
- Current Authority
- Individual Market: Individual: File and use for all rates. Increases can be justified if carrier shows compliance with minimum loss ratio (50-60 percent depending on renewal clause; NAIC model). K.A.R. 40-4-1
- Small Group Market: Small Group Market: K.S.A. 40-2215h allows carriers to file and use rate increases based on three factors: pricing component, case traits (age, group size, and geography) and utilization (limited to 15 percent annual adjustment). Increases cannot exceed 75 percent per year.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Kansas currently conducts prospective review of premium increases, but the review process is limited due to staff and funding constraints. The State will use the grant to enhance its review process by investing in new premium analysis systems and IT infrastructure and by acquiring additional staff and actuarial services dedicated to premium review. The net result of these enhancements will be that more rates are subjected to thorough actuarial review.
- Make More Information Publicly Available: Premium filings are not currently disclosed. Kansas will post premium filings and related summary reports on its website. Additionally, consumers will be able to comment on all proposed increases.
Kentucky
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. Case traits (age, gender, occupation, geography and health status) can vary 5:1, and ratings bands are +/- 35 percent. Carriers must meet lifetime loss ratio of 65 percent.
- Small Group Market: Small Group Market: Same authority as individual. Rating bands is +/- 50 percent. Groups (2-10) have a minimum loss ratio of 70 percent and groups (11-50) have a minimum loss ratio of 75 percent.
- Additional Legislative Authority: The State will propose legislation to expand the rate review process for large groups. In addition, actuarial consultants will evaluate whether revision or extension of laws are needed to enhance the rate review process.
- Expand the Scope of Health Insurance Premium Review: Currently the State reviews rate filings for individual, small group and association products. Only the rating methodologies are reviewed for large group products. The State will increase the categories of data required to be filed by large groups and will expand its review of large group rate filings to include analysis of rate factors.
- Improve the Health Insurance Premium Review Process: The DOI currently collects and can report on only a small portion of the data points needed. The State will increase the amount of data to be provided in a rate filing and will modify the review process to include consideration of plan years, underwriting issues and policy forms.
- Make More Information Publicly Available: Currently, information about health insurance rates is not readily available to the public. The DOI will develop a publication to explain the rate review process, including the information submitted by insurers and reviewed by the DOI. The DOI will make information available to the public, in plain language, to give notice of specific rate increases and decreases. In addition, the DOI will conduct surveys and hold open meetings for consumers in order to determine what information would be useful for them to make well-informed health insurance decisions.
- Current Authority
- Individual Market: Individual: Department does not have authority to deny rate increases. All rates are file and use.
- Small Group Market: Small Group Market: Same authority as individual. Compliance with small group rating reforms checked during financial audit.
- Additional Legislative Authority: Currently Louisiana does not have the authority to deny premium increases. The State will seek new authority to review and approve all major medical rates during the 2011 legislative cycle.
- Expand the Scope of Health Insurance Premium Review: New legislation could provide review and approval authority for all major medical products.
- Improve the Health Insurance Premium Review Process: Currently Louisiana does not have the authority to deny premium increases. Louisiana will develop a comprehensive legislative proposal to review and approve major medical rates. Louisiana will conduct review of all unreasonable rates per federal law. Upon enactment of legislation, Louisiana will review and approve major medical rates.
- Make More Information Publicly Available: Currently filings are only released upon court order or by permission of the insurer. The State is not proposing any transparency initiatives.
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department (24-A M.R.S.A. § 2736.). Age and geography case traits are permitted (1:5 to 1) and non-smoker discounts are permitted. Carriers must meet a 65 percent loss ratio (24-A M.R.S.A. § 2736-C(5)).
- Small Group Market: Small Group Market: Carriers may elect a three year average loss ratio guarantee with premium refund of 78 percent and avoid prior approval of rates. All other rates are subject to the prior approval of the Department and meet a 75 percent loss ratio. Large Group: Informational rate filing.
- Additional Legislative Authority: No.
- Expand the Scope of Health Insurance Premium Review: No.
- Improve the Health Insurance Premium Review Process: Currently the State reviews individual and small group filings for compliance with adjusted community rating. Only the small group filings lack sufficient detail to determine full compliance with the law. Maine plans to collect additional information on small group rates. Additionally they will collect historical and projected cost and utilization trend data to establish benchmarks.
- Make More Information Publicly Available: Currently, the Bureau posts extensive rate filing information on its website, and encourages consumer participation in the rate filing process by hosting field hearing in addition to formal hearings. Maine is encouraging increased participation of consumer advocacy groups in rate hearings and will compile submitted rate filing information into a consumer friendly format and post.
Maryland
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. Carriers must meet a minimum loss ratio of 60 percent. Age and family tier may be used to adjust the community rate.
- Small Group Market: Small Group Market: All rates require the prior approval of the Department. Traits include age, geographic location, and family tier as long as collectively these adjustments do not result in a premium that is more than 50 percent above or 50 percent below the community rate. The minimum loss ratio is 75 percent.
- Additional Legislative Authority: No.
- Expand the Scope of Health Insurance Premium Review: No.
- Improve the Health Insurance Premium Review Process: Currently MD conducts prospective actuarial review of all rate filings. To build upon its current process, Maryland plans to contract for consulting services to provide recommendations on which data elements should be included in rate filing submissions, which markets should require additional data elements in their rate filings and the implementation of policies and procedures to carry out a more robust rate review process.
- Make More Information Publicly Available: Currently only the portions of rate filings that exclude confidential information are publically disclosed. To enhance consumer access to premium information, MD will contract for recommendations on how to best present premium increase information to consumers and policymakers.
Massachusetts
- Current Authority
- Individual Market: Closed Individual Market (policies issued prior to market merger): Rates require the prior approval of the Department and can only vary by age and geography. Rates that vary over two standard deviations or 110 percent of the composite rate receive additional review.
- Small Group Market: Merged Market: All rates require the prior approval of the Department. Rates may not exceed a 2:1 band and carriers can use age, geography, industry, family size, tobacco use, and wellness program participation.
- Additional Legislative Authority: No.
- Expand the Scope of Health Insurance Premium Review: Currently, the Department has prior approval authority over Blue Cross Blue Shield, HMO and small group rates. The Department will expand filing requirements to the large group market.
- Improve the Health Insurance Premium Review Process: The Department will improve rate filing and review protocols by developing new analytic tools to evaluate rates. The filing requirements will be further refined and carriers must separate claims and administrative data into standardized buckets and develop new models to analyze rate data.
- Make More Information Publicly Available: Access to rate filings after an internal review is completed is available upon request at the Division. Using grant funds, the Division will modify its website to enhance product rate information posted to its website.
Michigan
- Current Authority
- Individual Market: Individual: Blue Cross Blue Shield rates require the prior approval of the Department. Rates are governed by MCL 550.1609, and must be adequate, not excessive, and equitable.. HMOs are required to file for approval rates for all product types (MCL 500.3501 et seq). HMO rates must be fair, sound, and reasonable in relation to the services provided and not unfairly discriminatory (MCL 500.3519). Commercial carriers are file and use, but must meet a 55 percent life-time loss ratio.
- Small Group Market: Small Group Market: Same authority as individual except commercial carriers are not required to file rates with the Department.
- Additional Legislative Authority: No.
- Expand the Scope of Health Insurance Premium Review: No.
- Improve the Health Insurance Premium Review Process: Currently Michigan reviews Blue Cross Blue Shield rates prospectively and consults with contracted actuaries as needed; however a more limited review process is in place for all other products. The State will contract with consulting actuaries to both perform targeted, in-depth analysis and review of health insurance rate filings made by health maintenance organizations and commercial carriers and to build process and procedures for a more general rate review program for these areas.
- Make More Information Publicly Available: Michigan currently provides access to rate filings upon request. The Department will conduct a feasibility study on extracting rate information from rate filings and posting rate information to a proposed website, and will also look to other States for rate transparency models. They will also move towards creating a public portal that will provide consumer-friendly information to the public.
Mississippi
- Current Authority
- Individual Market: Individual: Companies may not implement a rate increase without receiving notification that the Department has acknowledged and filed the rate. Increases greater than 25 percent require a hearing.
- Small Group Market: Small Group Market: Regulation 73-4 (Miss. Code Ann. § 83-9-5(7)) and Bulletin 94-1 requires initial rate filings and rate increases to be filed and reviewed prior to implementation. Increases must be acknowledged before prices go into effect. Increases greater than 25 percent require a hearing.
- Additional Legislative Authority: Under current law, the DOI does not approve rate filing other than for Medicare Supplement and Long Term Care. The DOI will seek legislation to provide for rate review and approval of other health insurance products.
- Expand the Scope of Health Insurance Premium Review: The State intends to require rate review and approval of all health insurance products not currently reviewed.
- Improve the Health Insurance Premium Review Process: The DOI proposes to completely overhaul its existing system of health insurance rate review, including regulations, bulletins, standards, IT systems and internal protocols.
- Make More Information Publicly Available: Consumers are not now able to search health insurance rate filings. The DOI proposes to post on its website information on how health insurance rates are determined and to provide access to rate filings, rate increases and the justifications for increases. The DOI also proposes to develop ways to communicate this information to rural consumers who don't have Internet access.
Missouri
- Current Authority
- Individual Market: Individual: State has no explicit statutory rate review authority. Rates are not required to be filed with the Department.
- Small Group Market: Small Group Market: State only requires annual actuarial certification filing with the Director purporting that carrier is in compliance with applicable state laws. State has no statutory rate review authority.
- Additional Legislative Authority: No.
- Expand the Scope of Health Insurance Premium Review: Currently, rates are not required to be filed with the Department. The Department anticipates that the new federal law will provide additional authority to review rates and proposes to develop a new rate review process for the individual and small group markets.
- Improve the Health Insurance Premium Review Process: No current filing requirement. Missouri proposes to use grant funds to construct a data system which will house rates and related increases filed for use. This data system will provide the structure and mechanism for the actuaries to perform rate analysis.
- Make More Information Publicly Available: Health insurance rates are not required to be filed, so there is no mechanism for public access to rates and rate filings. Under the grant, the Department will post real-time rate filing information on its website and include actual rates and carrier justification for rate increases in a consumer -friendly format. The Department will also post rate review procedures on its website, and will provide consumers with email notification when carriers file rate requests.
Montana
- Current Authority
- Individual Market: Individual: State has no explicit statutory rate review authority. Rates are not required to be filed with the Department. Although the state has no statutory rate review authority, the department has general authority to request any information, including information about rates. Failure to produce information to the Department may result in a fine of $25,000 per incident.
- Small Group Market: Small Group Market: Subject to 25 % rate bands and to rate restrictions based on claims experience, health status, and duration of coverage. Actuarial certifications are filed annually, certifying that those rates are in compliance with the rate band statutes and the rate increase requirements. The state may request more information to determine whether or not the company complies with the rate band and the rate increase limitation.
- Additional Legislative Authority: Currently, the Commissioner of Securities and Insurance (CSI) has limited authority to review rates. The Commissioner intends to draft a bill to present to the legislature in 2011 that will grant the CSI rate review and approval authority over major medical health insurance rates.
- Expand the Scope of Health Insurance Premium Review: Currently, individual market carriers are not required to file rates. Small group market carriers must file actuarial certification that rating rules are in compliance with Montana law. MT will seek to obtain authority to require all major medical health insurance rates to be filed, reviewed and approved in all markets.
- Improve the Health Insurance Premium Review Process: Montana does not have any legal authority requiring major medical rates to be filed with or reviewed by CSI. The proposed rate filing law will provide review and approval authority and enable CSI to enforce all rating protections that exist in the ACA. Additionally the proposed law may include other rating factors to review and approve rate filings (administrative expenses; reasonable and excessive; and actuarially soundness). If MT is not granted additional authority by the legislature, grant funds will be used to improve enforcement of its existing rating laws and new Federal laws; expand targeted market conduct examinations; complete more in-depth analysis of small group actuarial certifications and rating manuals; and enhance consumer protections.
- Make More Information Publicly Available: Although the CSI does not have statutory authority to receive rate filings, it does provide certain consumer oriented insurance information on its website. Under this grant program, MT will propose a rating law that allows for a consumer comment period via website, telephone or mail, in addition to allowing consumers to request a public hearing. CSI will also provide detailed rate information, such as rate increase requests and rating trends, on the consumer friendly website. MT also plans to contract with a public relations firm to develop consumer oriented materials and to host 7 public awareness events Statewide.
- Current Authority
- Individual Market: Neb. Rev. Stat. § 44-710 requires carriers file rates before they become effective. The Director can notify insurer if benefits are unreasonable in relation to the premium charged, and insurer must discontinue use.
- Small Group Market: Small Group Market: Same rate review standard as the individual market. In addition, carriers must demonstrate compliance with rating reforms (Neb. Rev. Stat.§44-5258).
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: The Department of Insurance (DOI) will determine whether to require additional information in rate filings in order to improve the current process. DOI does not currently use outside consultants for rate review. It will retain an outside, certified actuary to conduct an additional, more detailed review of rate filings, and to develop a rate review procedures manual for use by existing staff.
- Make More Information Publicly Available: Transparency will be increased by providing information about health insurance rates on the DOI website. Consumers will be informed when rate increases take effect. A web-based tool will be developed to enable consumers to evaluate the value of their benefits.
Nevada
- Current Authority
- Individual Market: Individual: All carriers must receive the prior approval of the Department before implementing new prices. Rates cannot be excessive, inadequate or unfairly discriminatory. Annual increases may not be 15 percent above another block of business.
- Small Group Market: Small Group Market: All Blue Cross Blue Shield and HMO rates are subject to the prior approval of the Commissioner. All other carriers must file rates before use and demonstrate compliance with rating reforms.
- Additional Legislative Authority: There are now no rate filing requirements for small or large group PPO products; the DOI has prior approval authority for individual and HMO rates. It will propose legislation in the 2011 session to give it prior approval authority for rates for group health benefit plans. The DOI is currently required to keep actuarial data in rate filings confidential; it will seek legislation to make rate filings publicly available when filed.
- Expand the Scope of Health Insurance Premium Review: The State will seek legislation to enable it to review small and large group health plan rate filings.
- Improve the Health Insurance Premium Review Process: Currently all individual rates are reviewed. The State will use grant funds to seek greater review authority and hire staff to accommodate review of all major medical product lines.
- Make More Information Publicly Available: Currently the State provides access to approval rates and rating factors. Using grant funds they will create a new position of Consumer Advocate for Health Insurance Customers, who may seek a hearing on rate filings requesting unreasonable rate increases and will represent the interests of consumers at the hearing.
New Hampshire
- Current Authority
- Individual Market: Individual: All rates are subject to the prior approval of the Department. 60 to 75 percent anticipated loss ratio depending on renewal clause for new business.
- Small Group Market: Small Group Market: Same authority as the individual market.
- Additional Legislative Authority: No.
- Expand the Scope of Health Insurance Premium Review: No.
- Improve the Health Insurance Premium Review Process: Currently, the State has prior approval authority over all individual and small group market major medical products. NH will improve its existing filing requirements by collecting additional information such as administrative costs, overall carrier finances and historical data to determine the reasonableness of proposed rate increases. NH may use data from improved rate filings to retrospectively review rates.
- Make More Information Publicly Available: New Hampshire currently provides access to rate filings upon request at its office. NH will create a web portal that allows consumer access to rate filing information and provides plain language summaries of rate filings that explain changes in rates, identify key drivers, actuarial value, and anticipated impact on premiums.
New Jersey
- Current Authority
- Individual Market: Individual: Pre-reform (IHC) rates require prior approval of the Department (55 percent minimum loss ratio). IHC rates are officially file and use, but all rates are reviewed, and carriers must meet the 80 percent minimum loss ratio. Rates can vary 3.5 to 1 on age, gender, and geography.
- Small Group Market: Small Group Market: Carriers must file rates with the Department before use. All rates are reviewed for compliance and the 80 percent minimum loss ratio. Rating reforms require 2 to 1 variation using age, gender, and geography.
- Additional Legislative Authority: No.
- Expand the Scope of Health Insurance Premium Review: No.
- Improve the Health Insurance Premium Review Process: Currently individual and small group rates are reviewed by a credentialed actuary. NJ will contract with an actuarial firm for a comprehensive study and suggested redesign of the rate filing and review process to include standardization of formats, electronic filing, analytical tests, economic analysis, etc. The grant will also increase staff dedicated to rate review, allowing for in-depth review and allow for systems improvements, establish analytical tests and economic analysis.
- Make More Information Publicly Available: New Jersey provides access to rate filings upon request. The grant will enable New Jersey to establish a web site populated with rate filing information and consult with Rutgers for meaningful consumer input to information for the public.
New Mexico
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. The new minimum loss ratio is 71 percent, and review is based on if "benefits offered are unreasonably restricted in relation to the premium charged." Premium refunds are required if rates exceed the high-risk pool.
- Small Group Market: Small Group Market: State requires carriers to file rates before becoming effective. HMOs rates require the prior approval of the Commissioner. Carriers must provide actuarial certification demonstrating compliance with rating reforms.
- Additional Legislative Authority: Legislation will be introduced to allow better transparency and require the division to post rate filings on its website as well as to set forth the authority to release information to the public, which insurers will be required to provide.
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Currently all rate requests are subject to a review and approval process that includes a tiered approach; a more in-depth review (trends analysis of historical MLR, evaluation of medical cost index and comparison of claims and financial Statement data) for proposed increases greater than 5%. The DOI proposes to implement actuarial review of unreasonable rates and strengthen the rate review process by developing procedures that incorporate and implement federal regulations and State laws. The DOI intends to develop a Consumer and Business Services Bureau within the Insurance Division responsible for approving rates for the individual, small group and portability health insurance markets.
- Make More Information Publicly Available: The DOI provides access to rate filings upon request. The DOI will propose legislation that will make rate filings public information and require the Division to post rate filings on its website once they are deemed complete.
New York
- Current Authority
- Individual Market: Individual: 82 percent minimum loss ratio. Effective in Sept 2010, all new forms and revised rates are subject to the prior approval of the Department. Rates cannot be rate is unreasonable, excessive, inadequate or unfairly discriminatory. Individual products are community rated (geography and family size adjustments only).
- Small Group Market: Small Group Market: Same authority as individual. Carriers must demonstrate minimum loss ratio of 82 percent.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: The grant program will be used to implement the new prior approval law passed in 2010. Under the new law all rates will be subject to prior approval which includes adding large group review to the existing individual and small group review.
- Improve the Health Insurance Premium Review Process: Effective 2010, all new forms and revised rates are subject to the prior approval of the Department. Rates cannot be determined as unreasonable, excessive, inadequate or unfairly discriminatory. NY plans to standardize and streamline rate filings, develop a checklist for material to be submitted in connection with future rate filings, develop specifications for more detailed market segment reporting and develop a more standardized structure for reporting claims experience.
- Make More Information Publicly Available: Currently New York only posts premium rates on its website. NY plans to update its website to provide general information on the rate filing process in addition to providing a public forum in which consumers can comment on rate increases.
North Carolina
- Current Authority
- Individual Market: Individual: All rates are subject to the prior approval of the Department. Rates are disapproved if benefits provided are unreasonable in relation to the premium charged (50-65 percent loss ratio depending on renewal clause).
- Small Group Market: Small Group Market: The Department reviews rating factors. HMO and Blue Cross Blue Shield rates are subject to the prior approval of the Department.
- Additional Legislative Authority: Currently all individual rates are subject to prior approval. Legislative action will be taken to expand review authority, standardize data collection and to require simplified summary information be submitted by insurers for consumers use.
- Expand the Scope of Health Insurance Premium Review: The State will expand to prior approval of small group, large group and individual association plans.
- Improve the Health Insurance Premium Review Process: The State has individual rate review currently. They are seeking expanded authority and will improve the reporting and data collection.
- Make More Information Publicly Available: Currently all filings free of confidential information are posted on the web. The department is seeking authority to require insurers to create consumer friendly summaries. Consideration and planning for public comment and hearings will be explored.
North Dakota
- Current Authority
- Individual Market: Individual: All rates are subject to prior approval and a form must be disapproved if the benefits provided are unreasonable in relation to the premium charged. 55 percent minimum loss ratio.
- Small Group Market: Small Group Market: Same review authority as the individual market. 70 percent minimum loss ratio.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: North Dakota currently requires preapproval of rate increases in both individual and small group markets. The State intends to make improvements by providing better analytical tools for review and developing a multi-layer team review approach for efficiency.
- Make More Information Publicly Available: Rate filings are not actively disclosed to the public, but they are available upon request. In addition, rate requests and approvals for the health insurance company with the largest market share in the State are available on their website. Improvements are planned to provide more consumer friendly information to the public.
- Current Authority
- Individual Market: Individual: All rates are subject to the prior approval of the Department. Rate denials occur if superintendent finds that the benefits provided are unreasonable in relation to the premium charged.
- Small Group Market: Small Group Market: HMO rates are subject to the prior approval of the Department. All other carriers must file rates and justification with the Department and filings are reviewed for soundness and rating law.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Ohio has authority to review and preapprove individual rate filings; all small group rate filings are subject to retroactive review. Large group rating methodologies are also reviewed. Grant funding will be used to hire additional staff for review and upgrade processes, systems and data analysis capabilities.
- Make More Information Publicly Available: Currently Ohio publicly discloses HMO rate filings once they are approved. Rate filings for sickness and accident insurers are public when they are filed. The State intends to develop a consumer friendly web application, located on the department's website to assist consumers in using and understanding the rate filing information.
Oklahoma
- Current Authority
- Individual Market: Individual: HMO rates are subject to the prior approval of the Commissioner. No filing requirements for other carriers in the individual market.
- Small Group Market: Small Group Market: All rates are subject to the prior approval by the Commissioner. 60 percent minimum loss ratio, carriers are required to file rate manual prior to use, and compliance with rating provisions.
- Additional Legislative Authority: Oklahoma will seek statutory changes to provide specific authority for rate review including approval authority during the 2011 legislative session.
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: The State conducts limited rate review activities. HMOs and small group filings are required, however individual and large group products are not required to file. Oklahoma has the authority to require all rates to be filed. The State will use funds to expand activities to align with the existing authority for rate review in the State, improve processes, systems and pursue additional authority if determined necessary.
- Make More Information Publicly Available: The State currently provides consumers access to rate filings upon request via mail or by allowing viewing at the department's office. The State intends to create a consumer website to post the information on rate review. In addition, they plan to create consumer education materials including a report on the health insurance market in the State for consumers. They are also considering a consumer Ombudsman program.
Oregon
- Current Authority
- Individual Market: Individual: All rates are subject to prior approval by the Department and can be disapproved if benefits are not reasonable to premiums charged.
- Small Group Market: Individual: All rates are subject to prior approval by the Department and can be disapproved if benefits are not reasonable to premiums charged.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: The State intends to expand review to include large group unreasonable rate increases.
- Improve the Health Insurance Premium Review Process: Currently Oregon reviews all individual and small group rates for the purpose of justifying increase and compliance with community rating law. Grant funds will be used to develop and implement a large group market rate review process.
- Make More Information Publicly Available: Oregon has a robust consumer transparency program including posting of information, public comment, and consumer email notification. Grant funds will be used to move the Stakeholder engagement to the next level by developing administrative rules and publicly disclosing more meaningful information. In addition, they will fund a consumer advocacy organization to collect comments on rate filings.
- Current Authority
- Individual Market: Individual: All rates subject to the prior approval of the Commissioner; disapproval for rates determined to be excessive, inadequate, or unfairly discriminatory. 60 percent minimum loss ratio for commercial carriers.
- Small Group Market: Small Group Market: All Blue Cross (or Blue Shield) and HMO products require the prior approval for all rates. No filing requirement for commercial carriers or commercial affiliates of Blue Cross Blue Shield plans.
- Additional Legislative Authority: The state intends to engage legal services to investigate current and proposed statutory premium rate review authority, current regulatory authority and future legislative authority as well as the authority to use and disclose data collected from the industry.
- Expand the Scope of Health Insurance Premium Review: The state plans to analyze current regulatory authority and develop a plan to access rates for both regulated and non-regulated products.
- Improve the Health Insurance Premium Review Process: Currently the Commonwealth conducts actuarial review of individual market products. Commercial carriers are not required to file group rates. They intend to collect data from insurers in the individual and small group markets and will create a Health Insurance Rate Level Index database, which will be used as a resource for Department staff when reviewing rate filings and to develop comparison charts so that consumers can compare rates.
- Make More Information Publicly Available: Currently rate increases above 10% are published on the web. Using grant funds, the Commonwealth will provide rate information to the public and will develop enhanced consumer information, including premium comparisons and consumer education tools.
- Current Authority
- Individual Market: Individual: Blue Cross Blue Shield (only carrier in the market) is subject to the prior approval of the Department. A public hearing is required by statute.
- Small Group Market: Small Group Market: All rates are subject to the prior approval of the Commissioner. The rate factor review process for small and large group rates occurs in four steps over the course of 45-60 days. These steps include: (1) preliminary internal review, (2) public comment, (3) internal actuarial and substantive review, and (4) rate factors proposal to carriers.
- Additional Legislative Authority: No.
- Expand the Scope of Health Insurance Premium Review: The State will expand to include retrospective review of small group market rates.
- Improve the Health Insurance Premium Review Process: The State currently reviews all rates prospectively. Using grant funds, they will introduce compliance and quality to the affordability standards of health insurance premiums through a retrospective look back at the performance of the rate.
- Make More Information Publicly Available: Currently all "significant" rate increases are available on the web. Using grant funds the State will contract with a community organization to promote purchaser and consumer engagement including public comment. A consultant to increase web site traffic will also be used.
- Current Authority
- Individual Market: Individual: All rates are subject to the prior approval of the Director. The benefits provided must be reasonable in relation to the premiums charged S.C. Code Ann. §38.71.310 (2002). Minimum loss ratio is the NAIC model and varies from 50-60 percent depending on renewal clause.
- Small Group Market: Small Group Market: Rates are not subject to prior approval. They must file actuarial certification proving compliance with rating reforms.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Currently, South Carolina filings are reviewed by an analyst and referred to an actuary as needed. The State intends to hire a consultant actuary to review all individual and group rates. In addition, this review will result in new processes for comprehensive review of rate filings. Following this a determination regarding whether additional legislative authority is needed will be done.
- Make More Information Publicly Available: Actuarial study of historical rates and their reasonableness to consumers. Develop web site for consumer interface and public forum.
South Dakota
- Current Authority
- Individual Market: Individual: Blue Cross Blue Shield rates and commercial rates are subject to the prior approval of the Department. HMOs and some PPOs are technically file and use, but the Department indicates all file 30 days before effective date. Policies must meet a 65 percent loss ratio standard or be disapproved.
- Small Group Market: Small Group Market: Rates are not subject to prior approval. Carriers are required to maintain complete rate information and it may be requested by the Department at anytime. Carriers must adhere to small group rating reforms.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Currently South Dakota reviews only the individual market rate filings. Using grant funds, they will develop comprehensive rate review standards and internal rate review guidelines including adding a second level actuarial review.
- Make More Information Publicly Available: Currently rate filings are available upon request. Using grant funds, the division will establish a consumer friendly web portal to provide consumers with access to accident and health rate filing.
- Current Authority
- Individual Market: Individual: All rates and rate increases are subject to prior approval of the Department. Additionally, Commissioner may withdraw approval of any form, after proper notice and hearing, when she determines that the benefits are unreasonable in relation to the premium charged. TCA § 56-26-103. Minimum loss ratios range from 50-60 percent depending on renewal clause (NAIC model).
- Small Group Market: Small Group Market: Rates are not required to be submitted. If they are submitted upon request to verify compliance with TCA § 56-7-2209, they must be kept confidential.
- Additional Legislative Authority: Tennessee requires prior approval of individual rates only. Grant funding will be used to develop language to expand the review and to provide authority to disapprove submitted rates.
- Expand the Scope of Health Insurance Premium Review: The State will expand requirements to include both small and large group finings.
- Improve the Health Insurance Premium Review Process: Currently the State requires prior approval of individual rates only. Grant funds will be used for improvements to information systems and electronic data capture.
- Make More Information Publicly Available: Currently the department provides access to rate filings upon request and posts a spreadsheet on their website displaying rate changes. Grant funds will be used to hold monthly public hearings and consumer meetings, as well as publish information on the web.
Texas
- Current Authority
- Individual Market: Individual: All rates and rate increases are required to be filed prior to use. Rate increases in excess of 50 percent over a 12-month period require actuarial justification to be filed and are reviewed by the Department. Rate increases below 50 percent are filed for informational purposes only. In addition, any rate increase that generates a consumer complaint, regardless of the magnitude, is reviewed by the Department actuaries for compliance with actuarial principles.
- Small Group Market: Small Group Market: HMOs are required to file rates prior to use. Other carriers are not required to file rates, but must demonstrate compliance with rating reforms via actuarial certification.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Texas currently conducts limited rate reviews due to resource limitation. Using grant funds, the State intends to implement improved data collection and improve resource levels as well as undertake a more in depth review of rates.
- Make More Information Publicly Available: The State currently will provide access to rate filings upon request, however if the information is determined by the State to be confidential or a trade secret it is not available. With grant funds the State will develop a format and process of public disclosure of information including insurer justifications.
- Current Authority
- Individual Market: Individual: Utah does not have explicit rate review or prior approval authority. Individual carriers must file a rate manual with the Department 30 days before using the rate.
- Small Group Market: Small Group Market: The authority for the small group market is the same as the individual market. In addition, carriers are required to certify that they are in compliance with state rating reforms.
- Additional Legislative Authority: Currently Utah has no explicit authority to review or pre-approve rates. The State intends to develop legislative language to allow for expanded rate review in individual and small group markets and to add large group market review. In addition, language to allow public access to rate filing and creation of a web based portal for consumers will be developed. These will be presented in the 2011 session.
- Expand the Scope of Health Insurance Premium Review: Increase the number and expand the scope of review with the goal of 50% of the small and individual markets and to add large group market.
- Improve the Health Insurance Premium Review Process: Currently insurers are required to file rating manuals with the department before use. Grant funds will be used to create a comprehensive health insurance premium and rate filing review process. This will include development of review manuals as well as staff training.
- Make More Information Publicly Available: Currently all rate filings are deemed protected records under State law. The State will attempt to gain legislative authority to create a consumer web based environment, and will implement a public hearing process.
- Current Authority
- Individual Market: Individual: All rates are subject to the prior review and approval of the Department. Premiums must be community rated (8 V.S.A § 4080b.) In addition, the Commissioner must disprove any nongroup rates unless the anticipated loss ratios for the entire period for which rates are computed are at least 70 percent. 8 V.S.A § 4080b(m).
- Small Group Market: Small Group Market: All rates are subject to the prior approval of the Department.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: The State intends to expand the current scope of reviews to include large group coverage.
- Improve the Health Insurance Premium Review Process: Currently Vermont conducts prospective actuarial review on all filings. The filings of the largest insurers are referred to an actuarial contractor for a second level review. With grant funding they will develop standards for the review expansion and improve data collection and analysis.
- Make More Information Publicly Available: Currently Vermont provides hard copies of rate filings upon request at their office. Grant funds will be used to post layperson summaries on their existing web site and add comment functionality for consumers.
Virginia
- Current Authority
- Individual Market: Individual: Rates for all non-HMO must be given prior approval (in writing) by the Department. Premiums must be reasonable as defined by minimum loss ratio of 60 percent. HMO rates are not subject to prior approval. HMOs must file certification.
- Small Group Market: Small Group Market: Rates must be filed with the Department but are not subject to prior approval. HMO rules are the same as the individual market.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Virginia will expand the information required to be submitted with rate filings and will develop a procedures manual for the review of rate filings. They propose to do in-depth, targeted audits of rate filings of individual insurers with the largest market share and/or requesting the largest rate increases, in order to determine whether fundamental flaws in the process of developing rates exist and whether changes in the current rate review process are warranted.
- Make More Information Publicly Available: Virginia provides access to rate filings upon request. It publishes the "Health Insurance rates in Virginia" document on its web page. There are no plans for additional consumer actions with grant funds.
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. Carriers must comply with adjusted community rating (for geographic area, family size, age, tenure discounts, and wellness activities) and rates must be based on pooled medical experience across the market.
- Small Group Market: Small Group Market: All rates require the prior approval of the Department. Carriers must comply with adjusted community rating (geographic area, family size, age, and wellness activities).
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Washington State conducts in depth actuarial prospective rate review on all individual and small group health products. They intend to use grant funds to make IT system upgrades to the rate filing system that will improve collection, analysis, standardization and reporting of data.
- Make More Information Publicly Available: Current State law considers rate filing information proprietary, however they do currently publish all proposed rates for individual health plans on their website. Using grant funds the State will create a consumer website called “Consumer Care" for increased consumer transparency and awareness about the cost and quality of health care as a means to bring long term improvement to health care systems in the State.
West Virginia
- Current Authority
- Individual Market: Individual: All rates require the prior approval of the Department. Rates must be reasonable in relation to the benefits available under the policy and must meet a 65 percent lifetime loss ratio. Carriers may opt to guarantee a loss ratio (with refund).
- Small Group Market: Small Group Market: All rates require the prior approval of the Department. Carriers must adhere to small group rating reforms and to be eligible for an increase, carriers must have an anticipated loss ratio of 73 percent.
- Additional Legislative Authority: No
- Expand the Scope of Health Insurance Premium Review: No
- Improve the Health Insurance Premium Review Process: Currently, the DOI does not use any certified actuaries to review rate filings. DOI will hire consulting actuaries to review current rate filing requirements and recommend additional data elements needed to strengthen review process.
- Make More Information Publicly Available: The DOI will make modifications to its IT systems to be able to make public consumer-friendly descriptions of rate filings.
Wisconsin
- Current Authority
- Individual Market: Individual: Rates are reviewed and cannot be excessive, inadequate or unfairly discriminatory, nor shall an insurer charge any rate which if continued will have or tend to have the effect of destroying competition or creating a monopoly (Wis. Stat. § 625.11). In a competitive market, carriers may file and use rates. The Commissioner does have rate review authority (after a hearing) if rates violate the standard or if the market competition is not effective (Wis. Stat. § 625.21).
- Small Group Market: Small Group Market: Carriers must adhere to rating reforms (Wis. Stat. § 635.05) and are required to submit actuarial certification. The Department may require additional information such as rate manuals and rating factors.
- Additional Legislative Authority: Grant funds will be used to assess the need to pursue additional statutory authority to collect and review – on an ongoing basis – detailed rate information for the large group market.
- Expand the Scope of Health Insurance Premium Review: Wisconsin currently reviews rate filings for the individual market and will expand rate review to non group and group markets.
- Improve the Health Insurance Premium Review Process: Wisconsin currently reviews rate filing for the individual market using actuaries in a limited way. Grant funds will be used for actuarial consulting to develop more rigorous standardized requirements. Funding will also be used to assess the need for additional legislative or needed authority actions.
- Make More Information Publicly Available: The State currently publishes rate filings on their website and insurers are required to provide 60 days notice to consumers for increases. Using grant funds, the State will develop a public hearing and comment process and create more understandable information and explanations for consumers.