28 Tex. Admin. Code § 11.703 - Filings and Supporting Documentation

An HMO must submit schedule of charges information with the certificate of authority application in compliance with § 11.204(11) and (12) of this title (relating to Contents). After the commissioner issues a certificate of authority, the HMO must file rates and supporting documentation before use as follows:

(1) rates for a new product:

(A) evidences of coverage to which the rates apply;

(B) for individual and small group plans, a new rate sheet including rates for each plan and each combination of rating factors used by the HMO; and

(C) actuarial memorandum:

(i) a brief description of benefits and general marketing method;

(ii) a brief description of how rates were determined, including a general description and source of each assumption used;

(iii) a list of retention components, including, but not limited to, expenses, taxes, fees, and profit expressed as a percent of premium, dollars per policy, or dollars per unit of benefit;

(iv) the target loss ratio, including a brief description of how it was calculated and all components used in its calculation;

(v) a description of the experience used in developing the HMO's rates, including the level of credibility and appropriateness of experience data, and justification for the use of proposed manual rates if the HMO's own experience is not credible;

(vi) the assumptions and support used in developing rates, including, but not limited to, adjustments for trend, morbidity, lapses, risk-mitigating programs, and changes in benefits;

(vii) any other data used to support the proposed rate; and

(viii) an actuarial certification required by § 11.702 of this title (relating to Actuarial Certification);

(2) rate adjustments for an existing product:

(A) evidences of coverage to which the rates adjustments apply;

(B) for individual and small group plans, a new rate sheet that includes rates for each plan and each combination of rating factors used by the HMO; and

(C) actuarial memorandum:

(i) a brief description of benefits and general marketing method;

(ii) the scope and reason for the rate revision;

(iii) a description of the experience used in developing the HMO's rates, including past experience, loss ratio(s) for all applicable prior experience periods, the level of credibility and appropriateness of experience data;

(iv) a brief description of how revised rates were determined, including a general description and source of each assumption used, which must also include a list of expenses, taxes, fees, and profit, expressed as a percent of premium, dollars per policy or dollars per unit of benefit, or both;

(v) the target loss ratio and description of how it was calculated;

(vi) the assumptions and support used in developing rates, including, but not limited to, adjustments for trend, morbidity, lapses, risk-mitigating programs, and changes in benefits;

(vii) any other data used to support the proposed rate increase; and

(viii) an actuarial certification required by § 11.702 of this title.

Notes

28 Tex. Admin. Code § 11.703

The provisions of this §11.703 adopted to be effective January 1, 1980, 4 TexReg 4626; amended to be effective August 17, 1992, 17 TexReg 5359; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2242, eff. 8/1/2017