211 CMR 41.11 - Further Review of Closed Guaranteed Issue Health Plan Rate Filing

Current through Register 1466, April 1, 2022

(1) Amended Filing. A Carrier that is notified that its Rate Filing for a Closed Guaranteed Issue Health Plan is subject to further review may, no later than 21 days following that notice, submit an amended Rate Filing in which its rates for that plan have been reduced by an amount to cause its Adjusted Composite Rate to be less than the Average Adjusted Composite Rate plus two Standard Deviations. The Carrier's amended Rate Filing shall then be reviewed in accordance with the standards in 211 CMR 41.00.
(2) Carrier's Submission of Additional Evidence. If a Carrier that is notified that its Rate Filing for a Closed Guaranteed Issue Health Plan is subject to further review does not submit an amended Rate Filing, such Carrier may, no later than 21 days following that notice, submit additional evidence, including an Actuarial Opinion and Memorandum, to show that:
(a) The rate filed is reasonable in relation to the benefits provided; or
(b) Its Adjusted Composite Rate would not have exceeded the Average Adjusted Composite Rate for that type of Closed Guaranteed Issue Health Plan by more than two Standard Deviations if its Adjusted Composite Rate had been further adjusted for the case mix of persons insured in that Carrier's Nongroup Health Plans in operation as of August 15, 1996, whom the Carrier anticipates will be covered in its Closed Guaranteed Issue Health Plan during the period of the proposed rates.
(3) Commissioner's Request for Additional Information.
(a) If the Commissioner requires additional information to make his or her determination on further review of the Carrier's Closed Guaranteed Issue Health Plan Rate Filing, the Commissioner shall, no later than 20 days after the submission of the Carrier's additional evidence, notify the Carrier in writing of the additional information required.
(b) A Carrier shall furnish the additional information no later than ten days after receipt of the Commissioner's notice.
(c) If, following receipt of the additional information, the Commissioner requires further additional information to make his or her determination, he or she shall, within ten days, notify the Carrier in writing of the further additional information required.
(d) The Commissioner may continue to request, and the Carrier shall continue to provide, further additional information according to the timetables established in 211 CMR 41.11(3)(c) until the Commissioner has received sufficient information to make his or her determination on further review of the Rate Filing.
(4) Commissioner's Determination on Further Review. No later than ten days after the Commissioner's receipt of the last submission further information from the Carrier on the Rate Filing, he or she shall make a written determination regarding:
(a) Whether the Adjusted Composite Rate filed, further adjusted for case mix pursuant to 211 CMR 41.11(2)(b) if the Carrier so proposes, would not have exceeded the Average Adjusted Composite Rate for that type of Closed Guaranteed Issue Health Plan by more than two Standard Deviations; or
(b) In the case of an Adjusted Composite Rate that exceeds the Average Adjusted Composite Rate by more than two Standard Deviations either because the rate, although further adjusted for case mix would still have exceeded the Average Adjusted Composite Rate for that type of Closed Guaranteed Issue Health Plan by more than two Standard Deviations or because the Carrier does not propose an adjustment for case mix, whether the rate filed is reasonable in relation to the benefits provided.
(5) Approval of Proposed Rate on Further Review. If, after completion of the further review, the Commissioner determines that the Carrier has demonstrated that:
(a) the Adjusted Composite Rate, further adjusted for case mix, would not have exceeded the Average Adjusted Composite Rate for that type of Closed Guaranteed Issue Health Plan by more than two Standard Deviations; or
(b) The rate is reasonable in relation to the benefits provided;

The Commissioner shall notify the Carrier that the Rate Filing is approved.

(6) Disapproval of Proposed Rate on Further Review. If after completion of the further review, the Commissioner determines that the Carrier has not demonstrated that:
(a) The Adjusted Composite Rate, further adjusted for case mix, would not have exceeded the Average Adjusted Composite Rate for that type of Closed Guaranteed Issue Health Plan by more than two Standard Deviations; and
(b) The rate filed is reasonable in relation to the benefits provided;

The Commissioner shall notify the Carrier that the Rate Filing is disapproved and of the Carrier's right to request a Proceeding.

Notes

211 CMR 41.11

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