CHAPTER Ins 4100
REQUIREMENTS FOR ACCIDENT AND HEALTH INSURANCE RATE SUBMISSIONS
Statutory Authority: RSA 400-A:15, I; RSA 404-G:6, IV; RSA 415:16;
RSA 415:18, I;
RSA 415:24, II(h); RSA 415-A:6; RSA 415-H:5; RSA
420-A:31;
RSA 420-B:21; RSA 420-G:14; 45 CFR Part 158.130
PART Ins 4101
Requirements GOVERNING ALL
Accident and Health Insurance Rate Submissions
Ins 4101.01 Purpose. The purpose of this part is to establish requirements for all
filings of accident and health insurance rates covered by this chapter.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-99
Ins 4101.02
Applicability and Scope. This
part shall apply to rate filings for all accident and health insurance policies
covered by this chapter, except long term care insurance policies or
certificates under RSA 415-D, Medicare supplement insurance policies or
certificates under RSA 415-F, credit insurance policies or certificates under
RSA 408-A, or group disability income insurance.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins 4101.03 Federal Regulations
Apply. The provisions of the US
Department of Health and Human Services regulation, 45 CFR Subtitle A, Subchapter
B Part 158 Issuer Use of Premium Revenue Reporting and Rebate, dated December
1, 2010, wherein referenced shall
apply to all carriers subject to the provisions of Ins 4100.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins 4101.04 Definitions. For the purposes of this part:
(a) “Carrier” means an entity subject to the
insurance laws and rules of this state, or subject to the jurisdiction of the
commissioner, that contracts or offers to contract to provide, deliver, arrange
for, pay for, or reimburse any of the costs of health care services, including
an accident and health insurance company, a health maintenance organization, a
nonprofit hospital and health service corporation, or any other entity
providing a plan of health insurance, health benefits, or health services;
(b) “Commissioner” means the insurance
commissioner of this state;
(c)
“Covered person” means a policyholder, certificate holder, subscriber, member,
enrollee, dependent, or other individual entitled to benefits under a health
benefit plan;
(d) “Department” means the New Hampshire
insurance department;
(e)
“National Association of Insurance Commissioners (NAIC)” means the organization
of state insurance regulators of the 50 United States, Washington, DC,
and the 5 US territories; and
(f) “NAIC System for Electronic Rate and Form
Filing (SERFF)” means the automated system for handling insurance policy rate
and form filings between regulators and insurance companies.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11
(from Ins 4101.03); ss by #10212, eff 11-1-12; ss by #12799, eff
6-10-19
Ins 4101.05 Rate Filing Review and Inventory
Procedures.
(a) All submissions shall be made by the carrier
or by a licensed rating organization on behalf of the carrier.
(b) When a submission is made on behalf of a
carrier, a letter or other document authorizing the rating organization to file
on behalf of the carrier shall be included with the submission.
(c) All submissions and all related
correspondence shall be made via SERFF.
(d) All submissions shall include a fully
completed NAIC uniform transmittal document, effective as of January 1, 2019,
that is signed by a representative of the carrier authorized to certify
compliance. This document shall be available as referenced in Appendix B and at
http://www.naic.org/industry_rates_forms_trans_docs.htm.
(e) All submissions shall include a complete list
identifying by number and title each form to which the rates apply.
(f) The department shall request additional
information as necessary. Carriers shall
have 30 days to respond to a request from the department for further
information pursuant to this chapter.
(g) Carriers resubmitting a previously disapproved
submission shall submit a complete, new submission that identifies and is
responsive to all comments made by the department. The new submission shall include all
correspondence from the previously disapproved submission.
(h) All submissions shall specify the date that
the rates are intended to be effective.
Unless specified otherwise in this chapter, rate submissions shall remain confidential until approved and
effective. Effective dates shall not
precede the approval date. All approved
submissions shall be available for public review upon the effective date of the
rates. Filings for individual and small
group market plans, including stand-alone dental plans, shall be available for
public review no later than the start of the annual open enrollment period set
by the U.S. Department of Health and Human Services pursuant to 42 U.S.C. 1803
l (c)(6)(B).
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11
(from Ins 4101.04); ss by #10212, eff 11-1-12; amd by
#10880, eff
7-10-15; ss by #12799, eff 6-10-19
Ins 4101.06 Rate Filing Submission Requirements.
(a)
A rate filing shall be submitted whenever a new policy,
rider, or endorsement form that affects benefits is submitted for approval or
whenever there is a change in the rates applicable to a previously approved
form. If the form does not require a
change in the premium, the submission shall include a complete explanation of
the effect of the rider or endorsement on the anticipated loss ratio.
(b)
The rate filing shall include all rates and rating formulae.
(c)
Rates, other than rate revisions, shall be filed with the policies,
riders, or endorsements to which they apply and not separately.
(d)
Every rate submission shall contain:
(1) Carrier information, including
the name and address of the carrier and the name, signature, title, direct
toll-free telephone number, and e-mail address of the person responsible for
the filing;
(2) The scope and purpose of filing
specifying whether this is a new form filing, a rate revision, or a justification
of an existing rate;
(3) A description of benefits
provided by each policy form and any riders or endorsements that may be used
with the form;
(4) In-force business statistics,
including policy count and annualized premium of New Hampshire policyholders or
certificate holders, as well as the number of covered persons who will be
affected by the proposed rate revision;
(5) A proposed effective date,
including a description of how the proposed rate revision will be implemented,
such as the next anniversary date or next premium due date; and
(6) The reasons for the revision,
if the filing is for a rate revision.
Source. #9938, eff 6-10-11 (from Ins 4101.05); ss by
#10212, eff 11-1-12; ss by #12799, eff 6-10-19
PART Ins 4102
REQUIREMENTS FOR INDIVIDUAL HEALTH INSURANCE SUBJECT TO RSA 420-G
Ins 4102.01 Purpose. The purpose of this part is to provide requirements for
the submission and the filing of individual health insurance rates for all
products that meet the definition of health coverage under RSA 420-G:2, IX.
This part establishes standards for determining the reasonableness of the
relationship of benefits to premiums.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins 4102.02 Applicability and Scope. This part shall apply to all rate filings for individual
health coverage plans subject to RSA 420-G.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins
4102.03 Definitions. For the purposes of this part:
(a) “Actuarial certification” means a written
statement signed by a member of the American Academy of Actuaries;
(b) “Actuarial
memorandum” means the document describing the basis on which rates were
determined and that includes other supporting documentation as required;
(c) “Anticipated loss ratio” means the
calculation of the medical loss ratio over a period that is at least as great
as the anticipated policy lifetime that does not exceed 20 years;
(d) “Case characteristics” means demographic or
other relevant characteristics considered by the individual carrier in the
determination of premium rates for an individual;
(e) “Durational medical loss ratio” means the
medical loss ratio calculated for a specified duration not to exceed 12 months;
(f) “Earned premium” means premium revenue
pursuant to 45 CFR Part 158.130;
(g) “Earned premium
adjustments” means federal and state taxes and licensing and regulatory fees
pursuant to 45 CFR Part 158.161 (a) and 158.162 (a)(1) and (b)(1);
(h) “Health coverage” means “health coverage” as
defined in RSA 420-G:2, IX;
(i) “Incurred claims”
means reimbursements for clinical services provided to enrollees, pursuant to
45 CFR Part 158.140;
(j) “Medical loss ratio” means “medical loss
ratio” as defined in 45 CFR Part 158.221(a);
(k) “Member” means “covered
person” as defined in Ins 4101.04(c);
(l) “Premium” means the total
amount due from a policyholder to an individual carrier for the provision of
health coverage;
(m) “Premium rate” means an amount per covered
person used to calculate premium;
(n) “Quality improvement
expenses” means amounts expended for activities that improve health care
quality pursuant to 45 CFR 158.150 and 45 CFR 158.151; and
(o) “Tier” means a category of enrollment to
which enrolled individuals can elect coverage, and includes, at a minimum, “single
person”, “couple”, and “family” tiers;
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins
4102.04 Underwriting and Issue
Requirements.
(a) A carrier offering health coverage in the
individual market:
(1) Shall make all of its individual health plans available
for purchase;
(2) Shall not make available or offer any coverage that has been
discontinued in accordance with RSA 420-G:6, VI or VII; and
(3) May limit health coverage offered to individuals based on
health status only to the extent allowed under federal law.
(b) Carriers shall vary rates for health coverage
in the individual market by using only the following allowable case
characteristics:
(1) The attained ages of the covered individual and any
covered dependents;
(2) The tier category or the number of covered individuals;
and
(3) The smoking status of the covered individuals
(c) Rating factors based on attained age and
smoking status shall be guaranteed for a 12 month rating period.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12 (from Ins 4103.04); ss by #12799,
eff 6-10-19
Ins 4102.05 Renewal Requirements. A carrier offering health coverage in the
individual market shall renew all of its individual health insurance plans
provided such plans are currently available for purchase.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #10212, eff 11-1-12 (from Ins 4103.05); ss by
#12799, eff 6-10-19
Ins 4102.06 Data Considerations and Notice
Requirements.
(a) Carriers shall maintain records of earned
premiums, incurred claims, and reserves for each calendar year and for each
policy form, including data for rider and endorsement forms that are used with
the policy form for so long as the carrier maintains rates on the policy.
(b) Notwithstanding (a) above, the carrier:
(1) May maintain separate data for each rider or endorsement
form;
(2) May submit a request to the department to combine
experience for the purposes of evaluating the data for rider and endorsement
forms in relation to premium rates and rate revisions if the rider and
endorsement forms provide similar coverage and provisions, are issued to
similar risk classes, and are issued under similar underwriting standards,
subject to the following:
a. Once a carrier combines experience pursuant
to this paragraph, the carrier shall not again separate the experience; and
b. The carrier shall provide experience data for
all issue years for all of the rider and endorsement policy forms that have
been combined for this purpose; and
(3) Shall provide the ratios of actual claims to the claims
expected according to the assumptions underlying the existing rates.
(c) In determining the credibility and
appropriateness of experience data, the carrier shall consider the following
relevant factors:
(1) Statistical credibility of premiums and benefits,
including:
a. Low exposure; and
b. Low loss frequency;
(2) Experience and projected trends relative to the kind of
coverage, including:
a. Inflation in medical expenses; and
b. Economic cycles affecting disability income
experience;
(3) The concentration of experience at early policy durations
where select morbidity and preliminary term reserves are applicable and where
loss ratios are expected to be substantially lower than at later policy durations;
and
(4) The mix of business by risk classification.
(d) The carrier shall consider the
effect of making the following adjustments on the anticipated loss ratio:
(1) Substitution of actual claim run-offs for claim reserves
and liabilities;
(2) Determination of loss ratios with the increase in policy
reserves subtracted from premiums rather than added to benefits;
(3) Accumulation of experience fund balances;
(4) Substitution of net level policy reserves for preliminary
term policy reserves;
(5) Adjustment of premiums to a monthly mode basis; and
(6) Other adjustments or schedules suited to the form and to
the records of the company.
(e) The data used to make adjustments as required
in (d) above shall be reconciled to the data required to calculate the anticipated loss ratio as
prescribed.
(f) If a carrier provides a quote to a
policyholder or prospective policyholder, where an alternative design exists
with premium savings that are greater than the anticipated out of pocket
expenses, the carrier shall disclose the availability of this policy
alternative. Deductibles, co-insurance,
and elimination periods shall be examples of benefit designs that shall be
considered in calculating this difference.
Variations in co-pays shall not be considered due to uncertainty with
regard to utilization.
(g) Pursuant to (f) above, this policy
alternative shall be made available on a guaranteed issue basis for renewal
quotes.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12 (from Ins 4103.09); ss by #12799,
eff 6-10-19
Ins
4102.07 Rate Filing Standards.
(a) Carriers shall calculate
the market rate in accordance with the following:
(1) The calculation shall reflect the carrier’s experience
for all the products it sells and maintains in the individual health insurance
market;
(2) Plan relativity factors that are used to modify the
carrier’s experience to a common market rate shall be the same factors that
were used to calculate the health coverage plan rates during the experience
period;
(3) The market rate shall be normalized for the average plan
relativity factor; and
(4) Other assumptions used by the carrier in the calculation
of the market rate shall be specified.
(b) The carrier shall calculate from the market
rate the health coverage plan rates for the coverages it will offer. The carrier shall provide plan relativity
factors used to calculate the health coverage plan rates from the market rate. Any changes to the health coverage plan rates
from the previously approved set of plan relativity factors shall be
highlighted and the basis for the same shall be documented.
(c) Carriers shall calculate premium rates for
individual policyholders from the health coverage plan rates through the
application of factors for allowable case characteristics as follows:
(1) Carriers may use attained age, but the ratio of the
largest factor attributable to age to the lowest factor attributable to age
shall not exceed 3.0; and
(2) Carriers may use tobacco use, but the ratio of the
largest factor attributable to tobacco use to the lowest factor attributable to
tobacco use shall not exceed 1.5.
(d) All submissions shall:
(1) Include an actuarial certification and an actuarial
memorandum consisting of various sections as prescribed herein;
(2) Be provided as electronic documents, in formats as
prescribed in paragraphs (e) through (m) below; and
(3) Be attached to the SERFF filing
under the supporting documents tab with the named components as prescribed herein.
(e) The actuarial memorandum shall include a
component labeled “Public Information” that contains an electronic workbook
that includes:
(1) A worksheet named “Cover Sheet” that includes the
following information:
a. Contact information; and
b. A statement indicating that
the filing includes all of the carriers individual health insurance rates, or
an explanation as to why it does not;
(2) A worksheet named “Proposed Rate Change and
Enrollment By Health Coverage Plan” that includes the following information for
each health coverage plan:
a. Plan codes or suitable plan identifier;
b. The number of expected or enrolled
policyholders and covered dependents;
c. The number of expected or enrolled
policyholders and covered dependents that will be impacted by the proposed rate
change; and
d. The proposed health coverage plan rate;
(3) A worksheet named “Plan Design and Plan Relativity
Factors” that includes the following information:
a. Carrier plan code or name;
b. Primary Care Provider (PCP) office visit
copay;
c. Specialist office visit copay;
d. Emergency department copay;
e. Outpatient surgery copay;
f. In-network single deductible;
g. In-network coinsurance;
h. In-network single out-of-pocket maximum;
i.
Indication if the deductible applies to all medical services;
j. Services to which the deductible does not
apply;
k. Indication if the deductible applies to
pharmacy services;
l. Indication if preventive services are covered
in full;
m. Indication if the health coverage plan type
covers mental health and substance services;
n. Indication if the health coverage plan has a
tiered network component;
o. Retail pharmacy single deductible generic;
p. Retail pharmacy single deductible brand
formulary;
q. Retail pharmacy single deductible brand
non-formulary;
r. Retail pharmacy copay generic;
s. Retail pharmacy copay brand formulary;
t. Retail pharmacy copay brand non-formulary;
u. Plan relativity factors for proposed rates;
v. Policy form number;
w. Indication if the health coverage plan is
open or closed;
x. Indication if the health coverage plan is
grandfathered or non-grandfathered by federal definition;
y. Renewability of the health coverage plan;
z. General marketing method;
aa. Issue age limits; and
ab. Indication if the health coverage plan is
new;
(4) A worksheet named “Experience Used in the Rate
Development” that includes a brief description of the source for the experience
data and per member per month (PMPM) claims information for:
a. Inpatient facility;
b. Outpatient facility;
c. Professional services;
d. Prescription drugs;
e. Capitation arrangements;
f. Other provider payments; and
g. Other;
(5) A worksheet named “Administrative Charges” that includes
administrative charges as PMPM amounts;
(6) A worksheet named “Retention Charges” that includes
information for retention charges segmented by:
a. Administrative costs;
b. Investment income credits;
c. Contributions to surplus or profit; and
d. Other;
(7) A worksheet named “Illustrative Rates” that delineates
the final rates for 2 hypothetical policyholders;
(8) A worksheet named “Summary of Rating Factors” that
provides information regarding the carrier’s utilization of allowable rating
factors;
(9) A worksheet named “Health Coverage Plan Rate PMPM
Development for Standard Health Coverage Plan” that delineates how the health
coverage plan rate is calculated for prescribed standard plans including the
following information:
a. PMPM experience data;
b. Annual trend factor;
c. Months of trend;
d. Trend adjustments; and
e. PMPM retention; and
(10) A worksheet named “Medical Loss Ratio Exhibit for
Individual Market” that includes documentation regarding calculation of the
anticipated loss ratios with the following information:
a. Member months;
b. Incurred claims;
c. Earned premium;
d. Quality improvement expenses;
e. Earned premium adjustments; and
f. Interest rate assumption.
(f) The actuarial memorandum shall include a
component on the supporting documentation tab in SERFF labeled “Supporting
Public Information” with an attached portable document file (PDF) document that
includes:
(1) An exhibit titled “Discussion of Credibility” that
includes references to the sources for experience data, limitation on using
plan specific experience, and any explanation for experience
adjustments;
(2) An exhibit titled “Illustrative Rates” that delineates
the rate development for 2 hypothetical policyholders;
(3) An exhibit titled “Rating Factors” that includes rate
factor tables for each rating factor;
(4) An exhibit titled “Expected Distribution of Rating
Factors” that includes information delineating the expected distribution of
membership by allowable rating factors with tier and conversion factors; and
(5) An exhibit titled “Description of Methodology for the
Projected Medical Loss Ratio” that includes a discussion of data sources and
pricing assumptions used to calculate the anticipated loss ratio.
(g) The actuarial memorandum shall include a component
on the supporting documentation tab in SERFF labeled “Confidential Information”
that contains a Microsoft Excel or compatible workbook that includes a
worksheet named “Detail on Final Trend Assumptions” with trend assumptions
segmented by:
(1) Service categories, including:
a. Inpatient facility;
b. Outpatient facility;
c. Professional services;
d. Prescription drugs; and
e. Other; and
(2) Changes in:
a. Unit cost; and
b. Utilization.
(h) The actuarial memorandum shall include a
component on the supporting documentation tab in SERFF labeled “Supporting
Confidential Information” with an attached PDF document that includes:
(1) An exhibit titled “Description of Trend Development” that
includes an explanation of the process used to develop trend assumptions; and
(2) An exhibit titled “Supporting
Schedules for Trend Development” that includes documentation and other data to
support the trend assumptions.
(i) Actuarial
memoranda for rate revisions shall modify the worksheets required above as
follows:
(1) The worksheet named “Cover Sheet” shall include the
following additional information:
a. A statement certifying that there have been
no changes to rating methodology since the most recently approved filing or a
brief description of any such proposed changes; and
b. A statement certifying that there have been
no benefit changes to any of the plans for which rates are being revised or a
description of those benefit changes;
(2) The worksheet named “Proposed Rate Change and Enrollment
by Health Coverage Plan” shall include the following additional information:
a. PMPM health coverage plan rate in effect 12
months prior to the proposed rate effective date; and
b. PMPM health coverage plan rate from the most recently
approved filing;
(3) The worksheet named “Plan Design and Plan Relativity
Factors” shall include:
a. Plan relativities for coverage in effect on
the rate effective date one year prior to the rate filing effective date; and
b. Supporting documentation for plan relativity
factor changes that exceed 5%;
(4) The worksheet named “Detail on Final Trend Assumptions”
shall include the total annualized trend assumption from the most recently
approved rate filing;
(5) The worksheet named “Administrative Charges” shall
include:
a. The administrative charges used for coverages
in effect on the rate effective date one year prior to the rating filing
effective date; and
b. The administrative charges from the carrier’s
most recently approved filing;
(6) The worksheet named “Retention Charges” shall include:
a. The retention charges used for coverages in
effect on the rate effective date one year prior to the rate filing effective
date; and
b. The retention charges from the carrier’s most
recently approved filing;
(7) The worksheet named “Summary of Rating Factors” shall
include an indication as to which of the rating factors have changed since the
most recently approved rate filing; and
(8) The worksheet named “Health Coverage Plan Rate PMPM
Development for Standard Health Coverage Plan” shall include:
a. The standard health coverage plan rates,
PMPM, for coverages in effect on the rate effective date one year prior to the
rate filing effective date; and
b. The standard health coverage plan rates, PMPM,
which were approved in the carrier’s most recently approved filing.
(j) Actuarial memoranda for rate revisions shall
include a component titled “Additional Required Public Information for Rate
Revisions” that contains an electronic workbook with the following:
(1) A worksheet named “History of Rate Changes” that
summarizes rate filings the carrier made over the prior 3 years including:
a. The rate effective date;
b. The average, annual proposed rate change; and
c. The average, annual approved rate change;
(2) A worksheet named “Distribution of Rate Changes” that
includes the number of enrolled policyholders and covered dependents that will
be impacted by the proposed change segmented by the anticipated rate change;
and
(3) A worksheet named “Components of Average Proposed Rate
Change” that includes the average rate change attributable to rate changes in:
a. Utilization;
b. Unit costs;
c. Retention;
d. Benefit changes required by law;
e. Other benefit changes;
f. Over or under statement of prior rates; and
g. Other.
(k) The actuarial memorandum for rate revisions
shall include a component on the supporting documentation tab in SERFF titled
“Supporting Documentation for the Additional Required Public Information for
Rate Revisions” with a PDF document titled “Description of Rating Factors” that
includes supporting documentation for any proposed changes to the rating
factors.
(l) Carriers shall submit a complete filing, at
least annually, that includes all of the documentation required for rate
revisions even if no changes in rates are being proposed. The purpose of the rate filing shall be to
demonstrate that the continued use of the previously approved rates is
appropriate.
(m) All submissions shall include an actuarial certification
provided as a PDF document attached to the supporting documentation tab in
SERFF
under the public information component with the following statements:
(1) A statement indicating that the filing conforms to
generally accepted actuarial principals;
(2) A statement that the entire filing is in compliance with
all applicable laws and rules;
(3) A statement that the premiums are not inadequate,
excessive, unfairly discriminatory, or unreasonable in relation to the
benefits;
(4) A statement that variations in health coverage plan
rates:
a. Shall not exceed the maximum possible
difference in benefits unless they are based on the following:
1. Expected utilization differences attributable
to plan design;
2. Expected administrative cost differences
attributable to plan design; and
3. Provider reimbursement variances attributable
to plan design; and
b. Do not vary based on the health status,
morbidity, or other demographics of the populations electing the varying plans;
(5) A statement indicating that premium rates are calculated
from health coverage plan rates and that premium rates vary from health
coverage plan rates using only allowable rating factors;
(6) A statement that benefits are neither excluded nor vary
by any of the allowable rating factors; and
(7) A statement indicating that the health plan coverages for
which rates are being filed are being actively marketed and are available to
both new issues and renewing policyholders.
(n) Carriers shall use the calendar year as the
rate effective period, such that:
(1) Rates quoted and established for new issues
and renewals shall not vary within the rate effective period; and
(2) Rates shall be guaranteed to the
policyholder, and shall not change, for 12 months from issue or renewal.
(o) Carriers shall file rates each year on or
before the uniform filing date established by the department, consistent with
annual guidance from the Center for Medicare and Medicaid Services (“CMS”), for
the coming calendar year. For rates subject
to 45 CFR Part 154, carriers shall, in addition to filing with the department,
make all filings required with CMS under federal regulations.
(p) Final approved rates for all individual
market filings shall be available for public review no later than the start of
the annual open enrollment period set by the U.S. Department of Health and
Human Services pursuant to 42 U.S.C. 1803 l(c)(6)(B).
(q) In accordance with RSA 91-A:5, IV, the
department shall maintain the confidentiality of the commercial and proprietary
trend assumptions and supporting documentation that is required to be submitted
under Ins 4102.07 (g) and (h).
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12 (from Ins 4103.07); amd by
#10880, eff 7-10-15; ss by #12799 eff 6-10-19; ss by #12799, eff 6-10-19
Ins 4102.08 Loss Ratio Standards.
(a) Carriers shall estimate the average monthly
premium for each health plan coverage based
on an anticipated distribution
of business by all significant criteria having a price difference, including:
(1) Age;
(2) Coverage amount;
(3) Dependent status; and
(4) Rider frequency.
(b) Carriers shall assume all policyholders elect
the monthly mode, unless such mode is not available, and shall consider fractional
premium loads in the average monthly premium calculation. If the monthly mode is not available,
carriers shall assume the mode selected or anticipated to be selected by the
greatest proportion of policyholders.
(c) For new health plan coverages, benefits shall
be deemed reasonable in relation to the proposed premiums, provided that the
anticipated loss ratio is at least as great as 70%.
(d) For rate revisions:
(1) If the policy forms constitute an open block, that
is they are still being actively marketed, then benefits shall be deemed
reasonable in relation to premiums, provided the revised rates meet the
following standards derived from the previously approved rate filing for the
form or forms:
a. The anticipated loss ratio over the entire future
period for which the revised rates are computed to provide coverage shall be at
least as great as the anticipated loss ratio calculated over the entire future
period using the durational loss ratios from the previously approved rate filing;
and
b. The anticipated loss ratio shall be at least
as great as the anticipated loss ratio from the previously approved; and
(2) If the policy forms constitute a closed block, that is
they are no longer being actively marketed, then the loss ratios in (d)(1) above
shall be adjusted so that no additional revenue is generated to support the
administration of these policy forms unless the demonstration includes
supporting documentation demonstrating that the cost to administer this
business has increased.
(e) Carriers may modify the loss ratio standards
in (c) and (d) based on anticipated enrollment and the credibility adjustments
allowed pursuant to 45 CFR Part 158.230.
(f) Carriers that fail to review their experience
and file rate revisions at least annually shall not be permitted to increase
rates beyond what would be needed to provide for just one year of experience
deviations. Carriers shall not submit
rate revisions in future years to recoup rate revisions disallowed by this
section.
(g) Carriers shall not use rate revisions to
recoup a prior year’s losses.
(h) Carriers under receivership or some other
similar department oversight shall be exempt from the restrictions in (f) and
(g) above.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
PART
Ins 4103 REQUIREMENTS FOR SMALL EMPLOYER
GROUP HEALTH INSURANCE SUBJECT TO RSA 420-G
Ins
4103.01 Purpose.
The purpose of this part is to provide requirements for the submission
and the filing of small employer group health insurance rates subject to RSA
420-G and to establish standards for determining the reasonableness of the
relationship of benefits to premiums.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins
4103.02 Applicability and Scope. This part shall apply to every small employer
health insurance policy, rider or endorsement form affecting health coverage that constitutes health coverage as
defined under RSA 420-G:2, IX. Franchise
insurance as defined in RSA 415:19 which is not group supplement insurance
shall be considered individual health insurance. Group supplemental insurance offered under
RSA 415:19 shall not be subject to this part.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins
4103.03 Definitions. For the purposes of this part:
(a) “Actuarial certification” means a written
statement signed by a member of the American Academy of Actuaries;
(b)
“Actuarial memorandum” means the document describing the basis on which rates
were determined and that includes other supporting documentation as required;
(c) “Anticipated loss ratio” means the
calculation of the medical loss ratio over the 12 month period that begins on
the rate effective date;
(d) “Case characteristics” means demographic or
other relevant characteristics of a small employer that are considered by the
small employer carrier in the determination of premium rates for the small employer;
(e) “Earned premium” means premium revenue
pursuant to 45 CFR Part 158.130;
(f) “Earned premium adjustments” means federal
and state taxes and licensing and regulatory fees pursuant to 45 CFR Part
158.161 (a) and 158.162 (a)(1) and (b)(1);
(g) “Eligible employee” means any employee who is
eligible for the employer’s sponsored health benefit plan and who regularly
works at least 15 hours per week, or at least half the weekly hours full-time
employees work, whichever is greater.
The term includes a sole proprietor, a partner of a partnership, and an
independent contractor, if these individuals are included as employees under
the small employer’s health benefit plan;
(h) “Employee” means employee under Section 3(6)
of Title I of the Employee Retirement Income Security Act of 1974 (ERISA);
(i) “Enrolled
employee” means an eligible employee who has elected coverage in the employer’s
sponsored health benefit plan;
(j) “Health coverage” means “health coverage” as
defined in RSA 420-G:2, IX;
(k) “Incurred claims” means reimbursements for
clinical services provided to enrollees, pursuant to 45 CFR Part 158.140;
(l) “List bill” means a method for computing
premium rates that are based on each enrolled employee’s attained age;
(m) “Medical loss ratio” means “medical loss
ratio” as defined in 45 CFR Part 158.221 (a);
(n) “Member” means “covered person” as defined in
Ins 4101.04(c);
(o) “Premium” means the total amount due from a
small employer policyholder to a small employer carrier for the provision of
health coverage;
(p) “Premium rate” means an amount per covered
person or an amount per enrolled employee used to calculate premium;
(q) “Quality improvement expenses” means amounts
expended for activities that improve health care quality pursuant to 45 CFR
158.150 and 45 CFR 158.151;
(r)
“Small employer” means any person, firm, corporation, partnership,
or group of affiliated companies that are eligible to file a combined tax
return and that is actively engaged in business that, on at least 50 percent of
the working days during the preceding calendar year, employed at least one
employee and no more than 50 eligible employees, the majority of whom are
employed within this state;
(s) “Small employer carrier” means a carrier that
offers health insurance to one or more small employers in this state;
(t) “Small employer health insurance plan” means
all policies or plans sold or marketed by a carrier that meet the definition of
health coverage under RSA 420-G:2, IX;
(u) “Subscriber” means an
enrolled employee as defined in (i) above; and
(v) “Tier” means a category of enrollment to
which enrolled employees can elect coverage, and includes, at a minimum, “single
employee,” “couple,” and “family” tiers.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins 4103.04 Underwriting
and Issue Requirements.
(a) A small employer carrier:
(1) Shall make all of its small employer health insurance
plans available for purchase; and
(2) Shall not make available for offer any coverage that has
been discontinued in accordance with RSA 420-G:6.
(b) The minimum participation percentage shall
be:
(1) Seventy-five percent when the plan is the sole plan being
sponsored by the employer group; and
(2) Thirty-seven point five percent when the plan is one of 2
or more plans being sponsored by the employer group.
(c) For the purposes of (a)(4) above, the total
number of eligible employees shall not include eligible employees who decline
coverage and are covered as a dependent on another person’s health coverage.
(d) Carriers shall only vary rates for health
coverage provided to small employers by using allowable case characteristics
that shall include:
(1) The attained ages of the covered population;
(2) The tier categories;
(3) The number of enrolled employees; and
(4) The type of industry in which the small employer is
engaged.
(e) For purposes of (d) above, small employer
carriers may use approximations to calculate allowable case characteristics
provided such approximation methods:
(1) Are used uniformly for all small employer groups;
(2) Use the attained ages of enrolled employees with tier-based
membership factors to approximate the attained ages of the covered population;
and
(3) Use a prior census to estimate the actual enrollment.
(f) Rates calculated at issue, or at renewal,
shall not change throughout the policy year if the allowable case
characteristics of a small employer group change.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins
4103.05 Renewal Requirements.
(a) A small employer carrier shall renew all its
small employer health insurance plans provided such plans are currently
available for purchase.
(b) Carriers shall use the same rating
methodology, list bill or composite bill, as in the prior period unless the
small employer consents in writing to a change in the calculation methodology.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins
4103.06 Disclosure.
(a) A health carrier shall provide the rate
disclosure form with each premium rate quote.
(b) The rate disclosure form shall include the
health coverage plan rate for the coverage elected, and any adjustment thereto,
for allowable case characteristics.
(c) For composite billed groups, the disclosure
form shall be provided for the single employee rate. For list billed groups, the disclosure form
shall be provided for each enrolled employee’s rate.
(d) Carriers may submit forms for department
review, in accordance with Ins 401. The
department shall approve forms that meet the requirements in this section.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
Ins
4103.07 Rate Filing Standards.
(a) Carriers shall calculate a market rate in
accordance with the following:
(1) The calculation shall reflect the carrier’s experience
for all the products it sells and maintains in the small group health insurance
market;
(2) Plan relativity factors that are used to modify the
carrier’s experience to a common market rate shall be the same factors that
were used to calculate the health coverage plan rates during the experience
period;
(3) The market rate shall be normalized for the average plan
relativity factor; and
(4) Other assumptions used by the carrier in the calculation
of the market rate shall be specified.
(b) The carrier shall calculate health coverage
plan rates for the coverages it will offer from the market rate. The carrier shall provide plan relativity
factors used to calculate the health coverage plan rates from the market rate. Any changes to the health coverage plan rates
from the previously approved set of plan relativity factors shall be
highlighted, and the basis for the same shall be documented.
(c) Carriers shall calculate premium rates for
each small employer from the health coverage plan rate through the application
of factors for allowable case characteristics as follows:
(1) Carriers may use attained age, however, the ratio of the
largest factor attributable to age to the lowest factor attributable to age
shall not exceed 3.0; and
(2) Carriers may use tobacco use, however, the ratio of the
largest factor attributable to tobacco use to the lowest factor attributable to
tobacco use shall not exceed 1.5.
(d) All submissions shall:
(1) Include an actuarial certification and an actuarial
memorandum, consisting of the sections prescribed herein;
(2) Be provided as electronic documents, in formats as
prescribed in paragraphs (e) through (m) below; and
(3) Be attached to the SERFF filing under the supporting
documentation tab with the components prescribed herein.
(e) The actuarial memorandum
shall include a component labeled “Public Information” that contains an
electronic workbook that includes:
(1) A worksheet named “Cover Sheet” that includes the
following information:
a. Contact information;
b. A statement indicating that
the filing includes all of the carriers small group health insurance rates, or
an explanation as to why it does not; and
c. A statement indicating whether the carrier
utilizes list billing, and if so, a description of the groups being list
billed;
(2) A worksheet named “Proposed Rate Change and Enrollment by
Health Coverage Plan” that includes the following information for each health
coverage plan:
a. Plan codes or suitable plan identifier;
b. The number of expected or enrolled members,
subscribers, and groups;
c. The number of expected or
enrolled members, subscribers, and groups that will be impacted by the proposed
rate change; and
d. The proposed health coverage plan rate;
(3) A worksheet named “Plan Design and
Plan Relativities” that includes the following information:
a. Carrier plan code or name;
b. PCP office visit copay;
c. Specialist office visit copay;
d. Emergency department copay;
e. Outpatient surgery copay;
f. In-network single deductible;
g. In-network coinsurance;
h. In-network single out-of-pocket maximum;
i.
Indication if the deductible applies to all medical services;
j. Services that deductible does not apply to;
k. Indication if the deductible applies to pharmacy
services;
l. Indication if preventive services are covered
in full;
m. Indication if the health coverage plan covers
mental health and substance services;
n. Indication if the health coverage plan has a
tiered network component;
o. Retail pharmacy single deductible generic;
p. Retail pharmacy single deductible brand
formulary;
q. Retail pharmacy single deductible brand
non-formulary;
r. Retail pharmacy copay generic;
s. Retail pharmacy copay brand formulary;
t. Retail pharmacy copay brand non-formulary;
u. Plan relativity factors for proposed rates;
v. Policy form number;
w. Indication if the health coverage plan is
open or closed;
x. Indication if the health coverage plan is
grandfathered or non-grandfathered by federal definition;
y. Renewability of the health coverage plan;
z. General marketing method;
aa. Issue age limits; and
ab. Indication if the health coverage plan is
new;
(4) A worksheet named “Experience Used in the Rate
Development” that includes a brief description of the source for the experience
data and PMPM claims information for:
a. Inpatient facility;
b. Outpatient facility;
c. Professional services;
d. Prescription drugs;
e. Capitation arrangements;
f. Other provider payments; and
g. Other;
(5) A worksheet named “Administrative Charges” that includes
administrative charges as PMPM amounts;
(6) A worksheet named “Retention Charges” that includes
information for retention charges segmented by:
a. Administrative costs;
b. Investment income credits;
c. Contributions to surplus or profit; and
d. Other;
(7) A worksheet named “Illustrative Rates” that delineates
the final rate for 2 hypothetical groups;
(8) A worksheet named “Summary of Rating Factors” that
provides information regarding the carrier’s utilization of allowable rating
factors;
(9) A worksheet named “Health Coverage Plan Rate PMPM
Development for Standard Health Coverage Plan” that delineates how the health
coverage plan rate is calculated for prescribed standard plans including the
following information:
a. PMPM experience data;
b. Annual trend factor;
c. Months of trend;
d. Trend adjustments; and
e. PMPM retention; and
(10) A worksheet named “Medical Loss Ratio Exhibit Small Group
Market” that includes documentation regarding the calculation of the
anticipated loss ratio with the following information:
a. Member months;
b. Incurred claims;
c. Earned premium;
d. Quality improvement expenses; and
e. Earned premium adjustments.
(f) The actuarial memorandum shall include a
component on the supporting documentation tab labeled “Supporting Public
Information” with an attached PDF document that includes:
(1) An exhibit titled “Discussion of Credibility” that
includes references to the sources for experience data, limitation on using
plan specific experience and any explanation for experience adjustments;
(2) An exhibit titled “Illustrative Rates” that delineates
the rate development for 2 hypothetical groups;
(3) An exhibit titled “Rating Factors” that includes rate
factor tables for each rating factor;
(4) An exhibit titled “Expected
Distribution of Rating Factors” that includes information delineating the
expected distribution of membership by allowable rating factors with tier and
conversion factors; and
(5) An exhibit titled “Description of Methodology for the
Projected Medical Loss Ratio” that includes a discussion of data sources and
pricing assumptions used to calculate the anticipated loss ratio.
(g) The actuarial memorandum shall include a component
on the supporting documentation tab in SERFF labeled “Confidential Information”
that contains an electronic workbook that includes a worksheet named “Detail on
Final Trend Assumptions” with trend assumptions segmented by:
(1) Service categories, including:
a. Inpatient facility;
b. Outpatient facility;
c. Professional services;
d. Prescription drugs;
e. Other; and
(2) Changes in:
a. Unit cost; and
b. Utilization.
(h) The actuarial memorandum shall include a
component on the supporting documentation tab labeled “Supporting Confidential
Information” with an attached PDF document that includes:
(1) An exhibit titled “Description of Trend Development” that
includes an explanation of the process used to develop trend assumptions; and
(2) An exhibit titled “Supporting
Schedules for Trend Development” that includes documentation and other data to
support the trend assumptions.
(i) Actuarial
memoranda for rate revisions shall modify the worksheets required above as follows:
(1) The worksheet named “Cover Sheet” shall include the
following additional information:
a. A statement certifying that there have been
no changes to rating methodology since the most recently approved filing or a
brief description of any such proposed changes; and
b. A statement certifying that there have been
no benefit changes to any of the plans for which rates are being revised or a
description of those benefit changes;
(2) The worksheet named “Proposed Rate Change and Enrollment
by Health Coverage Plan” shall include the following additional information:
a. PMPM health coverage plan rate in effect 12
months prior to the proposed rate effective date; and
b. PMPM health coverage plan from the most
recently approved filing;
(3) The worksheet named “Plan Design and Plan Relativities”
shall include:
a. Plan relativities for coverage in effect on
the rate effective date one year prior to the rate filing effective date; and
b. Supporting documentation for plan relativity
factor changes that exceed 5%;
(4) The worksheet named “Detail Final Trend Assumptions”
shall include the total annualized trend assumption from the most recently
approved rate filing;
(5) The worksheet named “Administrative Charges” shall
include:
a. The administrative charges used for coverages
in effect on the rate effective date one year prior to the rate filing
effective date; and
b. The administrative charges from the carrier’s
most recently approved filing;
(6) The worksheet named “Retention Charges” shall include:
a. The retention charges used for coverages in
effect on the rate effective date one year prior to the rate filing effective
date; and
b. The retention charges from the carrier’s most
recently approved filing;
(7) The worksheet named “Summary of Rating Factors” shall
include an indication as to which of the rating factors have changed since the
most recently approved rate filing;
(8) The worksheet named “Health Coverage Plan Rate PMPM
Development for Standard Health Coverage” shall include:
a. The standard health coverage plan rates,
PMPM, for coverages in effect on the rate effective date one year prior to the
rate filing effective date; and
b. The standard health plan coverage rates,
PMPM, which were approved in the carrier’s most recently approved filing; and
(9) The worksheet named “Medical Loss Ratio Exhibit Small
Group Market” shall include the historical medical loss ratio for the 3
complete calendar years prior to the rate effective date.
(j) Actuarial memoranda for rate revisions shall
include a component titled “Additional Required Public Information for Rate
Revisions” that contains an electronic workbook with the following:
(1) A worksheet named “History of Rate Changes” that
summarizes rate filings the carrier made over the prior 3 years including:
a. The rate effective date;
b. The average, annual proposed rate change; and
c. The average, annual approved rate change;
(2) A worksheet named “Distribution of Rate Changes” that
includes the number of enrolled members, subscribers and groups that will be
impacted by the proposed change segmented by the anticipated rate change;
(3) A worksheet named “Components of Average Proposed Rate
Change” that includes the average rate change attributable to rate changes in:
a. Utilization;
b. Unit costs;
c. Retention;
d. Benefit changes required by law;
e. Other benefit changes;
f. Over or under statement of prior rates; and
g. Other.
(k) The actuarial memorandum for rate revisions
shall include a component on the supporting documentation tab in SERFF titled
“Supporting Documentation for the Additional Required Public Information for
Rate Revisions” with a PDF document titled “Description of Rating Factors” that
includes supporting documentation for any proposed changes to the rating
factors.
(l) Carriers shall submit a complete filing, at
least annually, that includes all of the documentation required for rate
revisions even if no changes in rates are being proposed to demonstrate that
the continued use of the previously approved rates is appropriate.
(m) All submissions shall include an actuarial
certification provided as a PDF document attached to the supporting
documentation tab in SERFF under the public information component with the
following statements:
(1) A statement indicating that the filing conforms to
generally accepted actuarial principals;
(2) A statement that the entire filing is in compliance with
all applicable laws and rules;
(3) A statement that the premiums are
not inadequate, excessive, unfairly discriminatory, or unreasonable in relation
to the benefits;
(4) A statement that variations in health coverage plan
rates:
a. Shall not exceed the maximum possible
difference in benefits unless they are based on the following:
1. Expected utilization differences attributable
to plan design;
2. Expected administrative cost differences
attributable to plan design; and
3. Provider reimbursement variances attributable
to plan design; and
b. Do not vary based on the health status/morbidity
or other demographics of the population electing the varying plans;
(5) A statement indicating that premium rates are calculated
from health coverage plan rates and that premium rates vary from health
coverage plan rates using only allowable rating factors;
(6) A statement that benefits are neither excluded nor vary
by any of the allowable rating factors; and
(7) A statement indicating that the health plan coverages for
which rates are being filed are being actively marketed and are available to
both new issues and renewing policyholders.
(n) Carriers shall make an annual filing for
rates. Carriers shall file rates each
year on or before the uniform filing date established by the department,
consistent with annual guidance from the Center for Medicare and Medicaid
Services (“CMS”), for the coming calendar year.
For rates subject to 45 CFR Part 154, carriers shall, in addition to
filing with the department, make all filings required with CMS under federal
regulations. Final approved rates for
all small group market filings shall be available for public review no later
than the start of the annual open enrollment period set by the U.S. Department
of Health and Human Services pursuant to 42 U.S.C. 1803 l(c)(6)(B).
(o) In addition to the required annual rate
filing, carriers may make interim filings no more than quarterly. Rate effective dates shall begin on the first
day of each quarter. Rates for interim
quarterly filings shall be available for public review on the rate effective
date.
(p) Upon issuance or renewal of a policy, the
rates for that policy shall be guaranteed to the policyholder, and may not
change, for 12 months from issue or renewal.
(q) In accordance with RSA 91-A:5, IV, the
department shall maintain the confidentiality of the commercial and proprietary
trend assumptions and supporting documentation that is required to be submitted
under Ins 4103.07 (g) and (h).
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; amd by #10880, eff 7-10-15;
ss by #12799, eff 6-10-19
Ins 4103.08
Loss Ratio Standards for Policy Forms.
(a) Carriers shall estimate the average annual
premium per policy form based on an anticipated distribution of business by all
significant criteria having a price difference, such as:
(1) Age;
(2) Coverage amount;
(3) Dependent status; and
(4) Rider frequency.
(b) Carriers shall assume all policyholders elect
a monthly mode. The average monthly
premium, for purposes of this section, shall be based on the rates being filed.
(c) With respect to all forms, benefits shall be
deemed reasonable in relation to the proposed premiums provided the anticipated
loss ratio is at least as great as 80 percent.
Carriers may modify this standard based on anticipated enrollment and
the credibility adjustments allowed pursuant to 45 CFR Part 158.230.
(d) The standards set forth in this section shall
apply to all new issues and shall apply to all other policy forms that are
issued or renewed that are not priced using durational premiums.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #10212, eff 11-1-12; ss by #12799, eff 6-10-19
PART Ins
4104 REQUIREMENTS FOR LARGE EMPLOYER
GROUP HEALTH INSURANCE
Ins
4104.01 Purpose. The purpose of this part is to provide
requirements for filing large employer group health insurance rates and to
establish standards for determining the reasonableness of the relationship of
benefits to premiums.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins
4104.02 Applicability and Scope. This part shall apply to every large employer
health insurance policy, rider, or endorsement form affecting health coverage
as that term is defined by RSA 420-G:2, IX.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #12799, eff 6-10-19
Ins 4104.03 Definitions. For the purposes of this part:
(a) “Actuarial certification” means a written
statement signed by a member of the American Academy of Actuaries, stating that
to the best of the actuary’s knowledge and judgment, the entire rate filing is
in compliance with all of the applicable laws and rules and that the benefits
are reasonable in relation to the premiums;
(b) “Actuarial memorandum” means the document
describing the basis on which rates were determined and that indicates and
describes the calculation of the anticipated loss ratio;
(c) “Anticipated loss ratio” means the
calculation of the medical loss ratio over a period that is at least as great
as the anticipated policy lifetime but does not exceed 20 years;
(d) “Case characteristics” means demographic or
other objective characteristics of a large employer that are considered by the
large employer carrier in the determination of premium rates for the large
employer;
(e) “Carrier” means any entity that provides
health insurance in this state, including insurance companies, health services
corporations, health maintenance organizations, fraternal benefit societies and
other entities subject to state insurance regulation;
(f) “Covered person” means any person covered
through large employer group health insurance and includes enrolled employees
and, if applicable, their dependents;
(g) “Durational medical loss ratio” means the
medical loss ratio calculated for a specified duration not to exceed 12 months.
(h) “Earned premium” means premium revenue
pursuant to 45 CFR Part 158.130;
(i) “Eligible
employee” means any employee who is eligible for the employer’s sponsored
health benefit plan and who regularly works at least 15 hours per week, or at
least half the weekly hours full-time employees work, whichever is
greater. The term includes a sole
proprietor, a partner of a partnership, and an independent contractor, if these
individuals are included as employees under the large employer’s health benefit
plan;
(j) “Employee” means an employee under Section
3(6) of Title I of the Employee Retirement Income Security Act of 1974 (ERISA);
(k) “Enrolled employee” means an eligible
employee who has elected coverage in the employer’s sponsored health benefit
plan;
(l) “Health coverage” means “health coverage” as
defined in RSA 420-G:2, IX;
(m) “Incurred claims” means
reimbursements for clinical services provided to enrollees, pursuant to 45 CFR
Part 158.140 plus amounts expended for activities that improve health care
quality pursuant to 45 CFR Part 158.150;
(n) “Large employer” means any person, firm,
corporation, or partnership that is actively engaged in business that, on at
least 50 percent of the working days during the preceding calendar year,
employs at least 51 employees who are eligible for employer sponsored coverage,
and the majority of whom are employed within this state;
(o) “Large employer carrier” means a carrier that
offers health insurance to one or more large employers in this state;
(p) “Medical loss ratio” means
“medical loss ratio” as defined in 45 CFR Part 158.221 (a); and
(q) “Tier” means a category of enrollment to
which enrolled employees can elect coverage and includes, at a minimum, “single
employee”, “couple”, and “family” tiers.
The term includes “tier membership”.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4104.04 Underwriting and
Issue Requirements.
(a) Large employer carriers shall file a report
with the department on or before March 1st of each year detailing for the prior
calendar year any instances where the carrier declined to offer coverage as
applied for and any instances where the carrier’s quoted renewal rate
represented an increase larger than the change in the health coverage plan rate
plus 10 percent.
(b) The report shall include the following
information:
(1) Policyholder identification number;
(2) Number of enrolled employees and number of
covered lives in both the calendar year for which the report is made and the
prior calendar year, if known; and
(3) The reason for the declination or the rate
increase.
(c) Carriers shall specify the case
characteristics used to vary rates.
(d) For each case characteristic in (c), the
filing shall specify:
(1) How the underwriting factor for that case
characteristic is used in the determination of the large employer’s premium
rate;
(2) The range of factors and the corresponding
range of impact on premium rates; and
(3) The expected average factor based on the
assumed distribution of business and the actual average factor based on the
actual distribution of business over the past 3 rating periods.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #12799, eff 6-10-19
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4104.06 Rate Filing Standards.
(a) Carriers shall calculate a market rate that
is representative of all of the RSA 420-G:2, IX health coverage plans offered
to large employers as follows:
(1)
Carriers shall provide the plan relativity factors that are used to
modify experience under its existing coverages so that the coverages can be
combined in the calculation of the market rate.
The plan relativity factors used to modify experience shall be the same
as those used to establish the health coverage rates when the coverages were
offered;
(2) Carriers shall provide annualized
trend information detailed to include cost, utilization, technology and other
components; and
(3)
Carriers shall specify all other assumptions used in the calculation of
the market rate.
(b) A carrier shall calculate health coverage
plan rates for the coverages it will offer as follows:
(1)
A carrier shall provide the plan relativity factors used to calculate
the health coverage plan rate from the market rate. Any changes to the health coverage plan rate
from the previously approved set of factors shall be highlighted and the basis
for the same shall be documented;
(2)
Variations in the health coverage plan rate shall be attributable to
variations in expected utilization or claims severity; and
(3)
Plan relativity factors shall not assume that there are differences in
the morbidity among individuals electing varied coverages.
(c) Carriers shall calculate premium rates for
each large employer from the health coverage plan rate through the application
of factors for case characteristics that are filed and approved by the
department.
(d) Supporting documentation shall include:
(1)
Recent claims for the previous 3 years under the previously approved rates;
(2)
A projection of how such experience compares to what was expected;
(3)
A breakdown for each previous calendar year and each policy year of
collected premium, earned premium, paid claims, paid loss ratio, change in claim
liability and reserve, incurred claims, incurred loss ratio, expected incurred
claims, actual-to-expected claims, and active life reserves;
(4)
Delineation of any changes in assumptions from those used in the
demonstration of the most recently approved rates;
(5)
Demonstration of compliance with the limitations delineated above;
(6)
Formulae, factors, and sample calculations demonstrating how premium
rates are actually computed;
(7)
Excerpts from the underwriting manual indicating how company personnel
are to apply rating variations;
(8)
Indication of the range of variation provided by the proposed factors
for each allowable case characteristic;
(9)
Indication of the expected distribution of rate factors, for each
allowable case characteristic, the carrier expects will apply as it underwrites
large employers;
(10)
Indication of the actual distribution of rate factors applied by the
carrier versus the expectation delineated in the rate filing where rates were
previously approved;
(11) A description of the morbidity basis used for
the form, including its source, any adjustments from the source,
and supporting data that justifies the morbidity basis;
(12) The average monthly premium rate
anticipated per enrolled employee and per covered individual;
(13)
For proposed rate adjustments, the average percentage increase,
and the largest percentage increase in the monthly premium rate anticipated per
enrolled employee and per covered individual, where the average increase is
determined by comparing the aggregate premium before and after the increase
assuming no lapses for all policies affected by the rate adjustment and where
the maximum increase is the largest increase for an in-force policy, accounting
for changes due to trend, aging, and allowable rating factors but excluding
changes in the group’s covered population;
(14)
The medical trend assumption and supporting documentation for the same;
(15)
Experience upon which rating assumptions can be based, except that when
there is insufficient experience within New Hampshire upon which rating
assumptions can be based, the carrier may use nationwide experience provided
that appropriate adjustments shall be made, including adjusting premiums to New
Hampshire levels and adjusting claims to represent New Hampshire utilization
and prices;
(16)
Premium adjustment information, except that no adjustment shall be made
if nationwide premiums include area factors that adjust premiums for variations
in utilization and price levels, provided that these factors result
in the same percentage adjustment to both premiums and claims;
(17)
A history of prior rate adjustments, including the approval date and
average percentage rate adjustments for the past 3 years;
(18)
Certification that the policy forms for which rates are being filed are
being actively marketed and are available to both new issues and renewing
policyholders;
(19)
Certification by a qualified actuary that, to the best of the
actuary’s knowledge and judgment, the entire rate filing is in compliance with
the applicable laws of New Hampshire and with the rules of the department;
(20)
A description of the benefits provided via the form;
(21)
A description of the expense assumptions;
(22)
Rate calculations for at least 2 different hypothetical groups; and
(23)
Sufficient documentation so that premium rates could be calculated for
any group.
(e) Carriers shall submit a complete filing
annually that includes all the documentation required by this section.
(f) Carriers may make an interim filing between
the required annual filings to propose rating adjustments.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4104.07 Loss Ratio Standards for New Policy Forms.
(a) Carriers shall estimate the average annual
premium per policy form based on an anticipated distribution of business by all
significant criteria having a price difference, such as:
(1)
Age;
(2)
Coverage amount;
(3)
Dependent status; and
(4)
Rider frequency.
(b) Carriers shall assume all policyholders elect
a monthly mode. The average monthly
premium, for purposes of this section, shall be based on the rates being filed.
(c) With respect to all forms, benefits shall be
deemed reasonable in relation to the proposed premiums provided the anticipated
loss ratio is at least as great as 85 percent.
Carriers may modify this standard based on anticipated enrollment and
the credibility adjustments allowed pursuant to 45 CFR Part 158.230.
(d) The standards set forth in this section shall
apply to all new issues and shall apply to all other policy forms that are
issued or renewed that are not priced using durational premiums.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
PART Ins 4105 REQUIREMENTS FOR GROUP STOP LOSS INSURANCE
Ins
4105.01 Purpose. The purpose of this part is to provide
requirements for the submission and the filing of group stop loss insurance
rates and to establish standards for determining the reasonableness of the
relationship of benefits to premiums.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins
4105.02 Applicability and Scope. This part shall apply to every group stop
loss health insurance policy, rider, certificate, or endorsement form affecting
stop loss health coverage.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins
4105.03 Definitions. For the purposes of this part:
(a) “Actuarial certification” means a written statement
signed by a member of the American Academy of Actuaries, stating that to the
best of the actuary’s knowledge and judgment, the entire rate filing is in
compliance with all of the applicable laws and rules and that the benefits are
reasonable in relation to the premiums;
(b) “Actuarial memorandum” means the document
describing the basis on which rates were determined and that indicates and
describes the calculation of the anticipated loss ratio;
(c) “Anticipated loss ratio” means the
calculation of the medical loss ratio over
a period that is at least as great as the anticipated policy lifetime but does
not exceed 20 years;
(d) “Case characteristics” means demographic or
other objective characteristics of a small employer that are considered by the
small employer stop loss carrier in the determination of premium rates for the
small employer;
(e) “Carrier” means any entity that provides stop
loss health insurance in this state, including insurance companies, health
services corporations, health maintenance organizations, fraternal benefit
societies, and other entities subject to state insurance regulation;
(f) “Durational medical loss ratio” means the
medical loss ratio calculated for a specified duration not to exceed 12 months;
(g) “Earned premium” means all monies paid by a
policyholder as a condition of receiving coverage;
(h) “Eligible employee” means any employee who is
eligible for the employer’s sponsored health benefit plan. The term includes a sole proprietor, a
partner of a partnership, and an independent contractor, if these individuals
are included as employees under the small employer’s health benefit plan;
(i) “Employee” means
an employee under Section 3(6) of Title I of the Employee Retirement Income
Security Act of 1974 (ERISA);
(j) “Enrolled employee” means an eligible
employee who has elected coverage in the employer’s sponsored health benefit
plan;
(k) “Health coverage” means “health coverage” as
defined in RSA 420-G:2 IX;
(l) “Incurred claims” means paid claims plus any
changes to claim reserves;
(m) “Large employer” means any person, firm,
corporation, or partnership that is actively engaged in business that, on at
least 50 percent of the working days during the preceding calendar year,
employs at least 51 employees who are eligible for employer sponsored coverage,
and the majority of whom are employed within this state;
(n) “Medical loss ratio” means
the ratio of incurred claims to earned premiums;
(o) “Premium” means the total amount due from a
small employer policyholder to a small employer stop loss carrier for the
provision of stop loss health coverage;
(p) “Rate” or “premium rate” means an amount per
covered person or an amount per enrolled employee used to calculate premium;
(q) “Small employer” means any person, firm,
corporation, or partnership that is actively engaged in business that, on at
least 50 percent of the working days during the preceding calendar year,
employed fewer than 50 employees, the majority of whom were employed within
this state;
(r) “Small employer stop loss carrier” means a
carrier that offers stop loss health insurance to one or more small employers
in this state; and
(s) “Tier” or means a category of enrollment to
which enrolled employees can elect coverage and includes, at a minimum, “single
employee” and “family” tiers. The term
shall include “tier membership”.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4105.04 Underwriting and
Issue Requirements.
(a) Small employer stop loss carriers shall file
a report with the department on or before March 15th of each year detailing for
the prior calendar year any instances where the carrier declined to offer
coverage as applied for and any instances where the carrier’s quoted renewal rate
represented an increase larger than 20 percent.
This report shall be filed at the same time as the actuarial
certification required pursuant to RSA 415-H.
(b) The report in (a) shall include the following
information:
(1)
Policyholder identification number;
(2) Number of enrolled employees in both the
calendar year for which the report is made and the prior calendar year, if
known; and
(3) The reason for the declination or the rate
increase.
(c) Carriers may only vary rates for stop loss
health coverage provided to small employers by using allowable case
characteristics.
(d) Allowable case characteristics shall include:
(1) The attained ages of the covered population;
(2) The number of enrolled employees; and
(3) The type of industry in which the small
employer is engaged.
(e) For purposes of (c) above, small employer
stop loss health carriers may use approximations to calculate allowable case
characteristics provided such approximation methods are used uniformly among
all small employer groups.
(f) Acceptable approximation methods include:
(1)
Using the attained ages of enrolled employees with tier based membership
factors to approximate the attained ages of the covered population; and
(2) Using a prior census to estimate the actual
enrollment.
(g) Rates calculated at issue, or at renewal,
shall not change throughout the policy year if the allowable case
characteristics of a small employer group change.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4105.05 Rate
Submission Requirements. Rate
filings for small and large employer group stop loss insurance shall include
the following:
(a) The specific formulas and assumptions used in
calculating gross premiums, including any changes in assumptions or formulas
made since the last filing;
(b) The expected claims costs;
(c) Identification of morbidity and mortality
tables or experience studies used and sufficient explanation for evaluation of
their validity, including copies of such tables if they are not currently
published;
(d) The range of commission rates and other fees
payable to producers or other persons except regularly salaried employees,
stated separately for new and renewal business;
(e) The expected loss ratio by policy duration;
(f) The anticipated loss ratio calculated over
the anticipated lifetime of the block of business, or 20 years, whichever is
shorter;
(g) Methods and assumptions used for making
projections, including any changes in methods or assumptions made since the
last filing; and
(h) Actual rates, or rating factors.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins
4105.06 Annual Filing Required. Small employer stop loss carriers shall
submit a filing that includes all documentation required of this subsection at
least annually.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins
4105.07 Interim Filing. Small employer stop loss carriers may make an
interim filing between its required annual filings, to propose adjustments to
only certain factors.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
PART Ins 4106
REQUIREMENTS FOR OTHER TYPES OF HEALTH INSURANCE
Ins 4106.01 Purpose. The purpose of this part is to provide requirements for
the submission and the filing of disability income health insurance rates,
blanket coverage, group supplemental coverage, and any other type of health
insurance that is defined as an excepted benefit under RSA 420-G:2, IX. This part establishes standards for
determining the reasonableness of the relationship of benefits to premiums.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4106.02 Applicability and Scope. This part shall apply to disability income insurance, blanket coverage, group supplemental
coverage, and any other type of health coverage that is identified as an excepted benefit under RSA
420-G:2, IX.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4106.03 Definitions. For the purposes of this part:
(a) “Actuarial certification” means a written
statement signed by a member of the American Academy of Actuaries that, to the
best of the actuary’s knowledge and judgment, the entire rate filing is in
compliance with all of the applicable laws and rules and that the benefits are
reasonable in relation to the premiums;
(b) “Actuarial memorandum” means the document
describing the basis on which rates were determined and that indicates and
describes the calculation of the anticipated loss ratio;
(c) “Anticipated loss ratio” means the
calculation of the medical loss ratio over a period that is at least as great
as the anticipated policy lifetime but does not exceed 20 years;
(d) “Blanket accident and health insurance” means
that form of accident and health insurance:
(1) Not requiring individual applications from
covered persons;
(2) Not requiring a carrier to furnish each person
with a certificate of coverage;
(3) Not constituting health coverage as that term
is defined in RSA 420-G:2, IX; and
(4) Covering special groups of persons as
enumerated in one of the following:
a. Under a policy issued to any common carrier,
which shall be deemed the policyholder, covering a group defined as all or any
class of persons who may become passengers on such common carrier;
b. Under a policy issued to an employer, who
shall be deemed the policyholder, covering all employees or any group of
employees defined solely by reference to exceptional hazards incident to such
employment; and
c. Under a policy issued to a college, school,
or other institution of learning, or to the head or principal
thereof, who or which are deemed the policyholder, covering students;
(e) “Disability income
insurance” means a policy or certificate that provides for periodic payments,
weekly or monthly, for a specified period during the continuance of disability
resulting from either sickness or injury or a combination of both.
(f) “Durational medical loss
ratio” means the medical loss ratio calculated for a specified duration not to
exceed 12 months;
(g) “Earned premium” means all monies paid by a
policyholder as a condition of receiving coverage;
(h) “Group supplemental health insurance” means
any accident or health policy or certificate that is sold or issued to a small
employer, large employer, licensed purchasing alliance, or a qualified
association trust that does not constitute health coverage as that term is
defined under RSA 420-G:2, IX;
(i) “Incurred claims”
means paid claims plus any changes to claim reserves;
(j) “Medical loss ratio” means the ratio of
incurred claims to earned premiums; and
(k) “Tier” or means a category of enrollment to
which enrolled employees can elect coverage and includes, at a minimum, “single
employee” and “family” tiers. The term
shall include “tier membership”.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4106.04 Submission Requirements.
(a) All submissions shall include an actuarial
memorandum, as follows:
(1) For new policy forms, the actuarial
memorandum shall include:
a. A brief description of:
1. The type of policy;
2. Benefits;
3. Renewability;
4. General marketing method;
5. Issue age limits; and
6. Rate determination, including all
assumptions;
b. Expense assumptions developed on a unit
basis, including:
1. Percent of premium;
2. Dollars per policy;
3. Dollars per unit of benefit; or
4. Any combination of the above;
c. Estimated average annual premium per policy;
d. Anticipated loss ratio, including a brief
description of how it was calculated, and anticipated durational loss ratio
assumptions;
e. Anticipated trend information by cost, utilization,
technology, and other components;
f. Anticipated loss ratio presumed reasonable
according to this part;
g. Actuarial certification; and
h. Rate sheet; and
(2) For rate revision requests, the actuarial
memorandum shall include:
a. A brief description of the:
1. Type of policy;
2. Benefits;
3. Renewability;
4. General marketing method; and
5. Issue age limits;
b. A statement indicating whether the policy
forms are:
1. An open block that is still available to new
issues; or
2. A closed block that is no longer being
sold;
c. Scope and reason for the rate revision,
including a statement indicating whether the revision applies only to:
1. New business;
2. Existing business; or
3. Both new and existing business;
d. An outline of all past increases that have
been approved and implemented on the form;
e. The estimated average annual premium per
policy calculated both before and after the rate increase;
f. A description of the relationship of the
proposed rate scale to the current rate scale;
g. Past experience as specified in paragraph (b)
below;
h. A brief description as to how revised rates
were determined, including a general description of and a source for each
assumption used;
i. Expense assumptions developed on a unit basis,
including:
1. Percent of premium;
2. Dollars per policy;
3. Dollars per unit of benefit; or
4. Any combination of the above;
j. The anticipated future loss ratio and a
description as to how it was calculated;
k. The anticipated loss ratio that combines past
and future experience and a description as to how it was calculated;
l. Anticipated trend information by cost,
utilization, technology, and other components;
m. The anticipated loss ratio presumed
reasonable according to this part;
n. Actuarial certification;
o. Current rate sheet for previously approved
rates; and
p. New rate sheet for proposed rates.
(b) Carriers shall maintain records of earned
premiums, incurred claims, and reserves for each calendar year and for each
policy form, including data for rider and endorsement forms that are used with
the policy form, however, the carrier:
(1) May maintain separate data for each rider or
endorsement form;
(2) May submit a written request to the department
to combine experience for the purposes of evaluating the data for rider and
endorsement forms in relation to premium rates and rate revisions if the rider
and endorsement forms provide similar coverage and provisions, are issued to
similar risk classes, and are issued under similar underwriting standards,
subject to the following:
a. Once a carrier combines experience pursuant
to this paragraph, the carrier shall not again separate the experience; and
b. The carrier shall provide experience data for
all issue years for all of the rider and endorsement policy forms that have
been combined for this purpose; and
(3) Shall provide the ratios of actual claims to
the claims expected according to the assumptions underlying the existing rates.
(c) In determining the credibility and
appropriateness of experience data, the carrier shall consider the
following relevant factors:
(1) Statistical credibility of premiums and
benefits, including:
a. Low exposure; and
b. Low loss frequency;
(2) Experience and projected trends relative to
the kind of coverage, including:
a. Inflation in medical expenses; and
b. Economic cycles affecting disability income
experience;
(3) The concentration of experience at early
policy durations where select morbidity and preliminary term reserves are
applicable and where loss ratios are expected to be substantially lower than at
later policy durations; and
(4) The mix of business by risk classification.
(d) The carrier shall consider the
effect of making the following adjustments on the anticipated loss ratio:
(1) Substitution of actual claim run-offs for
claim reserves and liabilities;
(2) Determination of loss ratios, with the
increase in policy reserves subtracted from premiums rather than added to
benefits;
(3) Accumulation of experience fund balances;
(4) Substitution of net level policy reserves for
preliminary term policy reserves;
(5) Adjustment of premiums to an annual mode
basis; and
(6) Other adjustments or schedules suited to the
form and to the records of the company.
(e) The data used to make adjustments as required
in (d) above shall be reconciled to the data required to calculate the anticipated loss ratio as
prescribed.
(f) Rate variations for different benefit plans
shall not exceed the maximum possible difference in benefits unless the carrier
demonstrates that the rate variation is based on expected utilization
differences attributable to the plan designs, independent of the anticipated
variation in health status or other demographics of the populations electing
the varying plans.
(g) If a carrier provides a quote to a
policyholder or prospective policyholder, where an alternative design exists
with premium savings that are greater than the anticipated out of pocket
expenses, the carrier shall disclose the availability of this policy
alternative. Deductibles, co-insurance, and
elimination periods shall be examples of benefit designs that should be
considered in calculating this difference.
Variations in co-pays shall not be considered due to uncertainty with
regard to utilization.
(h) Pursuant to (g) above, this policy
alternative shall be made available on a guaranteed issue basis for renewal
quotes.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
Ins 4106.05 Loss Ratio Standards for New Policy Forms.
(a) Carriers shall estimate the average annual
premium per policy form based on an anticipated distribution of business by all
significant criteria having a price difference, including:
(1)
Age;
(2) Coverage amount;
(3) Dependent status; and
(4) Rider frequency.
(b) Carriers shall assume all policyholders elect
a monthly mode. The average monthly
premium, for purposes of this section, shall be based on the rates being filed.
(c) With respect to new forms, benefits shall be
deemed reasonable in relation to the proposed premiums provided the anticipated
loss ratio is at least as great as:
(1) Sixty percent for optionally
renewable;
(2) Fifty-five percent for
conditionally renewable;
(3) Fifty percent for guaranteed
renewable;
(4) Forty-five percent for
non-cancelable; and
(5) Sixty percent for short term,
limited duration medical expense coverage.
(d) For policy forms that provide automatic indexing
of benefits in relation to some base that is not subject to control by either
the carrier or the insured, the carrier may file rates on a basis that provides
for automatic adjustment of premium rates on an actuarial basis, appropriate in
relation to the automatic adjustment in the benefits.
(e) If a carrier provides a quote to a
policyholder or prospective policyholder, where an alternative design exists
with premium savings that are greater than the anticipated out of pocket
expenses, the carrier shall disclose the availability of this policy
alternative. Deductibles, co-insurance,
and elimination periods are examples of benefit designs that shall be
considered in calculating this difference.
Variations in co-pays shall not be considered due to uncertainty with
regard to utilization.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11; ss by #12799, eff 6-10-19
Ins 4106.06 Loss Ratio Standards for Rate Revisions.
(a) Carriers shall estimate the average annual
premium, both before and after the revision, per policy form based on an
anticipated distribution of business by all significant criteria having a price
difference, including:
(1) Age;
(2) Coverage amount;
(3) Dependent status; and
(4) Rider frequency.
(b) Carriers shall assume all policyholders elect
the monthly mode, unless such mode is not available, and shall consider
fractional premium loads in the average annual premium calculation. If the monthly mode is not available,
carriers shall assume the mode selected, or anticipated to be selected,
by the greatest proportion of policyholders.
(c) If the policy forms constitute an open block,
that is, they are still being actively marketed, then benefits shall
be deemed reasonable in relation to premiums, provided the revised
rates meet the following standards derived from the previously approved rate
filing for the form or forms:
(1) The anticipated loss ratio over the entire
future period for which the revised rates are computed to provide coverage
shall be at least as great as the anticipated loss ratio calculated over the
entire future period using the durational loss ratios from the previously
approved rate filing; and
(2) The anticipated loss ratio
shall be at least as great as the anticipated loss ratio from the previously
approved filing where the anticipated loss ratio shall be computed by dividing:
a. The sum of the accumulated benefits from the
original effective date of the form to the effective date of the revision, and
the present value of future benefits; and
b. The sum of the accumulated premiums from the
original effective date of the form to the effective date of the revision, and
the present value of future premiums.
(d) If the policy forms constitute a closed
block, that is, they are not still being actively marketed, then the loss ratios in
Ins 4106.05 shall be adjusted so that no additional revenue is generated to
support the administration of these policy forms unless the demonstration
includes supporting documentation demonstrating that the cost to administer
this business has increased.
(e) Carriers that fail to review their experience
and file rate revisions at least annually shall not be permitted to increase
rates beyond what would be needed to provide for just one year of experience
deviations. Carriers shall not be
permitted to rate revisions in future years to recoup rate revisions disallowed
by this subsection.
(f) Carriers shall not be permitted rate
revisions to recoup prior year losses.
(g) Carriers under receivership or some other
similar department oversight shall be exempt from the restrictions in (e) and
(f) above.
Source. #9690, eff 4-9-10; ss by #9938, eff 6-10-11;
ss by #12799, eff 6-10-19
PART Ins 4107 WAIVER OF RULES
Ins 4107.01 Waiver
of Rules.
(a) The commissioner,
upon the commissioner’s own initiative or upon request by an insurer, shall
waive any requirement of this chapter if such waiver does not contradict the
objective or intent of the rule and:
(1) Applying the rule provision would cause
confusion or would be misleading to consumers;
(2) The rule provision is in whole or in part
inapplicable to the given circumstances;
(3) There are specific circumstances unique to
the situation such that strict compliance with the rule would be onerous without
promoting the objective or intent of the rule provision; or
(4) Any other similar extenuating circumstances
exist such that application of an alternative standard or procedure better
promotes the objective or intent of the rule provision.
(b) No requirement
prescribed by statute shall be waived unless expressly authorized by law.
(c) Any person or
entity seeking a waiver shall make a request in writing.
(d) A request for a
waiver shall specify the basis for the waiver and proposed alternative, if any.
Source. #12799, eff 6-10-19
APPENDIX A
Rule |
Specific State Statute the Rule Implements |
|
|
Ins 4101.01 |
RSA 400-A:15, I; RSA
415:1; RSA 415:24; RSA 420-A:2; RSA 420-A:8; RSA 420-B:20; RSA 420-G:1; RSA
420-G:4; RSA 420-G:12; RSA 420-G:13 |
Ins 4101.02 |
RSA 400-A:15, I; RSA
415:1; RSA 415:24; RSA 420-A:2; RSA 420-A:8; RSA 420-B:20; RSA 420-G:1; RSA
420-G:4; RSA 420-G:12; RSA 420-G:13 |
Ins 4101.03 |
RSA 400-A:15, I; 45 CFR
Subtitle A, Subchapter B Part 158 |
Ins 4101.04 |
RSA 400-A:15, I; RSA
420-B:20; RSA 420-G:1; RSA 420-G:2 |
Ins 4101.05 |
RSA 400-A:15, I; RSA
415:1; RSA 420-A:2; RSA 420-A:8; RSA 420-B:20; RSA 420-G:1; RSA 420-G:4; RSA
420-G:12; RSA 420-G:13 |
Ins 4101.06 |
RSA 400-A:15, I; RSA
415:1; RSA 420-A:2; RSA 420-A:8; RSA 420-B:20; RSA 420-G:1; RSA 420-G:4; RSA
420-G:12; RSA 420-G:13 |
|
|
Ins 4102.01 |
RSA 400-A:15, I; RSA
415:24; RSA 420-A:8; RSA 420-G:1; RSA 420-G:2, IX; RSA 420-G:4; RSA 420-G:12;
RSA 420-G:13 |
Ins 4102.02 |
RSA 400-A:15, I; RSA
420-G:1; RSA 420-G:4; RSA 420-G:12; RSA 420-G:13 |
Ins 4102.03 |
RSA 400-A:15, I; RSA
420-B:1; RSA 420-G:2; 29 U.S.C. 18
§ 1001 et seq.; 45 CFR Parts 158.130,
158.140, 158.150, 158.151, 158.221(a), 158.161(a), and 158.162(a)(1) and
(b)(1) |
Ins 4102.04 |
RSA 400-A:15, I; RSA
420-G:1; RSA 420-G:4; RSA 420-G:5; RSA 420-G:6; RSA 420-G:11; RSA
420-G:12; RSA 420-G:13 |
Ins 4102.05 |
RSA 400-A:15, I; RSA
420-G:1; RSA 420-G:4; RSA 420-G:5; RSA 420-G:6; RSA 420-G:11; RSA
420-G:12; RSA 420-G:13 |
Ins 4102.06 |
RSA 400-A:15, I; RSA
420-G:1; RSA 420-G:4; RSA 420-G:11; RSA 420-G:12; RSA 420-G:13 |
Ins 4102.07 |
RSA 400-A:15, I; RSA 420-G:1;
RSA 420-G:2; RSA 420-G:4; RSA 420-G:11; RSA 420-G:12; RSA
420-G:13; 42 U.S.C. 1803 l(c)(6)(B) |
Ins 4102.08 |
RSA 400-A:15, I; RSA
420-G:1; RSA 420-G:2; RSA 420-G:4; RSA 420-G:11; RSA 420-G:12; RSA
420-G:13; 45 CFR Part 158.230 |
|
|
Ins 4103.01 |
RSA 400-A:15, I; RSA
420-G:1; RSA 420-G:4; RSA 420-G:12; RSA 420-G:13 |
Ins 4103.02 |
RSA 400-A:15, I; RSA
415:19; RSA 420-G:1; RSA 420-G:2, IX; RSA 420-G:3; RSA 420-G:4; RSA 420-G:11;
RSA 420-G:12; RSA 420-G:13 |
Ins 4103.03 |
RSA 400-A:15, I; RSA
420-B:1; RSA 420-G:2; 29 U.S.C. 18
§ 1001 et seq.; 45 CFR Parts 158.130,
158.140, 158.150, 158.151, 158.221(a), 158.161(a), and 158.162(a)(1) and
(b)(1) |
Ins 4103.04 |
RSA 400-A:15, I; RSA
420-G:1; RSA 420-G:4; RSA 420-G:5; RSA 420-G:6; RSA 420-G:11; RSA
420-G:12; RSA 420-G:13 |
Ins 4103.05 |
RSA 400-A:15, I; RSA
420-G:1; RSA 420-G:4; RSA 420-G:5; RSA 420-G:6; RSA 420-G:11; RSA
420-G:12; RSA 420-G:13 |
Ins 4103.06 |
RSA 400-A:15, I; RSA
415:1; RSA 420-G:1; RSA 420-G:4; RSA 420-G:11; RSA 420-G:12; RSA 420-G:13 |
Ins 4103.07 |
RSA 400-A:15, I; RSA
420-A:2; RSA 420-A:8; RSA 420-B:20; RSA 420-G:1; RSA 420-G:4; RSA 420-G:11;
RSA 420-G:12; RSA 420-G:13; 42 U.S.C. 1803 l(c)(6)(B) |
Ins 4103.08 |
RSA 400-A:15, I; RSA
420-G:4(h); RSA 420-G:13; RSA 420-G:14; 45 CFR Part 158.230 |
|
|
Ins 4104.01 |
RSA 400-A:15, I; RSA 415:1; RSA 415:2; RSA 420-B:20; RSA 420-G:1; RSA 420-G:4; RSA
420-G:12; RSA 420-G:13 |
Ins 4104.02 |
RSA 400-A:15, I; RSA 415:1; RSA 415:24; RSA 420-A:2;
RSA 420-A:8; RSA 420-B:20; RSA 420-G:1; RSA 420-G:4; RSA 420-G:12; RSA
420-G:13 |
Ins 4104.03 |
RSA 400-A:15, I; RSA 415-A:1; RSA 420-A:1; RSA
420-B:1; RSA 420-G:2; 29 U.S.C. 18
§ 1001 et seq.; 45 CFR Part 158.130, 158.140, 158.150 |
Ins 4104.04 |
RSA 400-A:15, I; RSA 415:1; RSA 420-A:2; RSA
420-A:8; RSA 420-B:20; RSA 420-G:1; RSA 420-G:4; RSA 420-G:5; RSA 420-G:6;
RSA 420-G:11; RSA 420-G:12; RSA 420-G:13 |
Ins 4104.05 |
RSA 400-A:15, I; RSA 415:1; RSA 420-A:2; RSA
420-A:8; RSA 420-B:20; RSA 420-G:1; RSA 420-G:4; RSA 420-G:5; RSA 420-G:6;
RSA 420-G:11; RSA 420-G:12; |
Ins 4104.06 |
RSA 400-A:15, I; RSA 415:1; RSA 420-A:2; RSA
420-A:8; RSA 420-B:20; RSA 420-G:1; RSA 420-G:2, IX; RSA 420-G:4; RSA 420-G:11;
RSA 420-G:12; RSA 420-G:13 |
Ins 4104.07 |
RSA 400-A:15, I; RSA 415:1; RSA 415:2; RSA 415-A:6;
RSA 420-G:14; 45 CFR Part 158.230 |
|
|
Ins 4105.01 |
RSA 400-A:15, I; RSA 415-H:1; RSA 415-H:5 |
Ins 4105.02 |
RSA 400-A:15, I; RSA 415-H:1; RSA 415-H:5 |
Ins 4105.03 |
RSA 400-A:15, I; RSA 415-A:1; RSA 420-A:1; RSA
420-B:1; RSA 420-G:2; RSA 415-H:2; RSA 415-H:5 |
Ins 4105.04 |
RSA 400-A:15, I; RSA 415-H:3; RSA 415-H:5 |
Ins 4105.05 |
RSA 400-A:15, I; RSA 415-H:3; RSA 415-H:5 |
Ins 4105.06 |
RSA 400-A:15, I; RSA 415-H:4; RSA 415-H:5 |
Ins 4105.07 |
RSA 400-A:15, I; RSA 415-H:4; RSA 415-H:5 |
|
|
Ins 4106.01 |
RSA 400-A:15, I; RSA 415:1; RSA 415-A:6; RSA
420-G:2, IX |
Ins 4106.02 |
RSA 400-A:15, I; RSA 415:1; RSA 415-A:6; RSA
420-G:2, IX |
Ins 4106.03 |
RSA 400-A:15, I; RSA 415:1; RSA 415-A:1; RSA
420-A:1; RSA 420-B:1; RSA 420-G:2 |
Ins 4106.04 |
RSA 400-A:15, I; RSA 415:1; RSA 415:2; RSA 415-A:6 |
Ins 4106.05 |
RSA 400-A:15, I; RSA 415:1; RSA 415:2; RSA 415-A:6 |
Ins 4106.06 |
RSA 400-A:15, I; RSA 415:1; RSA 415:2; RSA 415-A:6 |
|
|
Ins 4107.01 |
RSA 400-A:15, I; RSA
541-A:22, IV |
APPENDIX B
Rule |
Title of Material |
Publisher; How to Obtain; Cost |
Ins 4101.05(d) |
Accident & Health Transmittal Document developed by the National Association of Insurance Commissioners, effective as of January 1, 2019 |
Published by the NAIC Available for no cost at: https://www.naic.org/industry_rates_forms_trans_docs.htm |