PR Carta Normativa Núm. CN-2014-175-AS
Radicaciones de Formularios y Tarifas Para el Año Natural de 2015
ESTADO LIBRE ASOCIADO DE PUERTO RICO
OFICINA DEL COMISIONADO DE SEGUROS
B5 Calle Tabonuco, Oficina 216 • PMB 356 • Guaynabo, PR 00968-3029 • Tel.: (787) 304-8686 • Fax: (787) 304-0099
www.ocs.gobierno.pr
24 de marzo de 2014
CARTA NORMATIVA NÚM. CN-2014-175-AS
A TODOS LOS ASEGURADORES DE INCAPACIDAD Y ORGANIZACIONES DE
SERVICIOS DE SEGUROS DE SALUD QUE SUSCRIBEN PLANES MÉDICOS EN
PUERTO RICO
RADICACIONES DE FORMULARIOS Y TARIFAS PARA EL AÑO NATURAL DE
2015
Estimados señores y señoras:
Conforme a la Sección 2794 de la Ley Federal de Servicio de Salud Pública, enmendada
en la Sección 1003 de la ley federal de Protección del Paciente y Cuidado Accesible
(“ACA”), y de conformidad con los Capítulos 8 y 10 del Código de Seguros de Salud de
Puerto Rico, los aseguradores que suscriben planes médicos individuales y para grupos
pequeños en Puerto Rico deben presentar a la Oficina del Comisionado de Seguros
(“OCS”) las tarifas nuevas para los productos que cumplen con la ACA, todas las tarifas
para los planes que cumplan con la ACA aunque no se haya hecho ningún cambio y los
cambios que sean de 10% o más de las tarifas actuales, para la revisión y aprobación de
las mismas. Todas las organizaciones de servicios de salud (HMO) deben cumplir con
los requisitos de radicar las tarifas con la OCS, tal como se dispone en la Sección
19.080(2) (a) del Código de Seguros de Puerto Rico, 26 L.P.R.A., sec. 1908(2)(a) así como
de radicar todos los cambios o modificaciones de las tarifas, incluidas las tarifas de los
planes que cumplen con la ACA, aunque no se haya hecho ningún cambio.
En aras de implementar guías adecuadas para fomentar la presentación ordenada de los
formularios y las tarifas de los planes, que entrarán en vigor el 1 de enero de 2015, la
OCS por la presenta promulga las siguientes normas:
Presentación de Tarifas
I. Calendario
Las radicaciones de tarifas que entrarán en vigor el 1 de enero de 2015 para los planes
individuales y de grupos pequeños que tengan derechos adquiridos se deben presentar
a la OCS en o antes del 30 de mayo de 2014. Todo asegurador que se proponga hacer
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cambios de tarifas trimestrales en los planes de grupos pequeños en 2015 debe radicar
las tarifas para todos los trimestres a más tardar el 31 de mayo de 2014.
Los aumentos de las tarifas para los planes individuales y de grupos pequeños de las
HMO con derechos adquiridos y los aumentos de tarifas mayores de 10% de los
aseguradores de incapacidad se tienen que radicar por lo menos con 90 días de
anticipación a la fecha de uso.
II. Requisitos para la radicación de tarifas
A. Toda radicación tiene que hacerse correctamente a través del sistema SERFF,
incluida la información que se requieren esta Carta Normativa y sus Anejos.
Véanse las instrucciones para radicar por SERFF en la Sección VI de esta
Carta Normativa.
B. Adviértase que las radicaciones incompletas se devolverán sin ser evaluadas.
C. Todos los archivos Excel se deben presentar en Excel, así como en formato
PDF para imprimir.
D. Toda radicación de tarifas se debe presentar conforme a los requisitos
establecidos en el Manual de Instrucciones para Radicar Tarifas en Puerto
Rico (Véase el Anejo 1).
E. Se requiere que los siguientes documentos se incluyan en la radicación de
tarifas:
1) “Federal Rate Review Justification Part I-Unified Rate Review Template”
(URRT 2015 versión en Excel y en PDF) (Véase “Federal Instructions
Manual and Standard Format” en el Anejo 2);
2) Formato de la información que se colocará en el sitio Web de la OCS y se
usará en la Parte II de la justificación federal: “Written explanation of any
rate increase that is 10% or more”; (versiones en inglés y español);
3) Memorando Actuarial que cumpla con los requisitos de Puerto Rico y de
la Parte III del Memorando Actuarial federal y las Instrucciones de
Certificación 2.0 de 2014. (Véase el Anejo 3);
4) Certificación Actuarial de Puerto Rico;
5) Imágenes de las pantallas del “Actuarial Value Calculator” (para planes
que cumplen con la ACA solamente);
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6) Plantilla SERFF de las tarifas (en Excel);
7) Manual de Tarifas;
8) Mapa de Beneficios Puerto Rico (si difiere del Mapa de Beneficios ya
radicado con la OCS o se debe indicar que ya se ha radicado el Mapa de
Beneficios (Véase el Anejo 4) y
9) Lista de Cotejo para las radicaciones de tarifas en Puerto Rico (Véase el
Anejo 5).
III. Uso de tarifas aprobadas y futuras revisiones
A. Los aseguradores solo pueden usar las tarifas radicadas y aprobadas por la
OCS.
B. No se pueden usar tarifas más bajas o más altas, aun cuando la tarifa revisada
es a nivel de grupo y la tarifa no es mayor que la tarifa aprobada. Nótese que
se harán auditorías para verificar que sólo se estén usando las tarifas
aprobadas.
C. No se permitirá que los aseguradores implementen cambios a las tarifas
actuales antes del 1 de enero de 2015, a menos que el asegurador pueda
probar que su solvencia económica disminuirá de manera peligrosa sin un
cambio de tarifas.
D. Una vez se aprueben las tarifas, no se pueden cambiar durante el año, a
menos que el asegurador pueda probar que su solvencia económica se verá
amenazada sin un cambio de tarifas.
E. Para el mercado de grupos pequeños, si las tarifas se aumentan
trimestralmente, se deben radicar por adelantado a la misma vez. No se
aceptará ningún otro aumento trimestral, a menos que el asegurador pueda
probarle a la OCS que las pérdidas proyectadas afectarían su solvencia.
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IV. Tarifas que se publicarán
A. Los únicos documentos que se publicarán en el sitio Web de la OCS después
de la aprobación son las tarifas y el resumen público de la información de la
radicación preparado por el asegurador para colocarse en el sitio Web de la
OCS.
B. Todos los documentos se divulgarán simultáneamente el 1 de septiembre de
2014.
V. Radicación de las tarifas no sujetas a la nueva legislación
A. Toda radicación se deberá hacer por medio del sistema SERFF e incluir toda
la información que se requiere en esta Carta Normativa y sus Anejos. Véanse
las instrucciones para radicar las tarifas mediante SERFF en la Sección VI de
esta Carta Normativa.
B. Adviértase que toda radicación incompleta se devolverá sin evaluación
alguna.
C Todos los archivos Excel se presentarán en Excel, además del formato PDF
para impresión.
D. Todo aumento en las tarifas de los HMO y de los aseguradores de
incapacidad que sea de 10% o más de las tarifas del año anterior se deberá
presentar conforme a los requisitos establecidos en el Manual de
Instrucciones para Radicar Tarifas en Puerto Rico (Anejo 1).
E. Los documentos antes mencionados en la partida II (E) de esta Carta
Normativa se deben incluir en la radicación de las tarifas.
VI. Presentaciones mediante SERFF
A. En toda radicación mediante SERFF se debe incluir una Carta de Trámite que
indique el nombre del asegurador o la organización de servicios de salud que
hace la radicación bajo la firma de una persona autorizada, en cumplimiento
con la Sección 3(a)(1) de la Regla XXIV del Reglamento del Código de Seguros
de Puerto Rico. La carta de trámite se debe adjuntar en la sección “Supporting
Documentation”.
B. Se deben completar todos los campos indicados en la sección “Rate Rule
Schedule”.
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C. Se debe incluir toda la documentación en la sección “Supporting
Documentation”, incluido el documento “Federal Rate Review Justification
Part I-Unified Rate Review Template” (URRT – tanto en el formato Excel
como en PDF), el formulario con la información sobre la radicación de tarifas
que se colocará en el sitio Web de la OCS, el Memorando Actuarial de Puerto
Rico, el Memorando Actuarial y la Certificación federal de 2014, la
Certificación Actuarial de Puerto Rico, las imágenes de la pantalla del
“Actuarial Value Calculator”, el Manual de Tarifas, el Mapa de Beneficios de
Puerto Rico y la Lista de Cotejo para la Radicación de Tarifas de Puerto Rico.
D. Las tarifas presentadas para aprobación se deben incluir en la sección “Rate
Rule Schedule”.
E. Los documentos se deben guardar en formato PDF sin protección, de manera
que se pueda realizar una búsqueda en el archivo y se pueda copiar texto del
documento.
F. Toda comunicación se debe incluir en el sistema SERFF como una “Note to
Reviewer (Nota al Revisor)” o “Response Letter (Carta de respuesta)”, como
sea aplicable. Cualquier otro medio de comunicación se dará por no recibido.
VII. Radicaciones de tarifas y formularios de grupos grandes
Las radicaciones para los grupos grandes no se deben presentar para la evaluación y
aprobación de la OCS. Esta norma no es aplicables a las HMO, las cuales tienen que
cumplir con las disposiciones de la Sección 19.080(2)(a) del Código de Seguros de
Puerto Rico.
Además, debemos señalar que los formularios de los grupos grandes están sujetos a
nuestra revisión y aprobación. Los formularios de los grupos tienen que cumplir con
todas las disposiciones aplicables de la ley ACA y del Código de Seguros de Salud de
Puerto Rico, que incluyen, entre otras, las siguientes Secciones de la ley de Servicio
Público de Salud: la Sección 2711 (Ausencia de límites anuales o vitalicios), la Sección
2713 (Cubierta de servicios de salud preventivos),1 la Sección 2714 (Extensión de
cubierta para dependientes), la Sección 2704 (Exclusiones de condiciones preexistentes).
Los formularios de los grupos grandes que no cumplan con la ley se tienen que
actualizar y radicar inmediatamente para la revisión y aprobación de esta Oficina.
“Supplemental Health Care Exhibit” (SHCE)
Por la presente se requiere que todos los aseguradores completen y envíen el
documento titulado “Supplemental Health Care Exhibit” a la NAIC y a la OCS antes del
30 de marzo, en el caso de los aseguradores de incapacidad, y antes del 31 de marzo de
cada año, en el caso de las organizaciones de servicio de salud.
1 No es aplicable a los planes con derechos adquiridos.
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Radicaciones de productos
I. Calendario
Las radicaciones de productos de planes individuales y de grupos pequeños que entran
en vigor el 1 de enero de 2015 se deben presentar a la OCS a más tardar el 31 de mayo
de 2014.
II. Requisitos para la radicación de productos
A. Toda radicación se debe hacer por medio del sistema SERFF con toda la
información que se requiere en esta Carta Normativa y sus Anejos. Véanse las
instrucciones para radicaciones de productos mediante SERFF en la Sección
IV de la presente Carta Normativa.
B. No se aceptará ningún endoso de un producto que cumpla con la ACA
previamente aprobado.
C. Adviértase que toda radicación incompleta se devolverá sin evaluación
alguna.
D. Todos los formularios y documentos se deben presentar en formato PDF para
impresión.
E. Los siguientes documentos tienen que incluirse en la radicación del producto:
1. Lista de Cotejo de Beneficios Esenciales de Salud y Servicios Preventivos
(Véase el Anejo 6).
2. Lista de Cotejo para radicación de formularios de Puerto Rico (Véase el
Anejo 7).
F. Todos los productos y la estructura de copagos se tienen que radicar a la
misma vez y no se pueden cambiar durante el año.
G. No se podrá radicar ningún producto nuevo de clasificación metálica para ser
efectivo en el año 2014.
H. Los productos que cumplan con la ACA que estarán vigentes en el año
natural de 2015 solo deben incluir un límite de gastos pagados por el
beneficiario (MOOP), lo cual incluye los medicamentos recetados. El límite
del MOOP para el año 2015 establecido por nuestra Oficina es de $6,350 para
la cubierta que es solamente del beneficiario y $12,700 para todo otro tipo de
cubierta.
I. Los aseguradores deben mercadear todos los productos que cumplan con la
ACA y estén aprobados por la OCS.
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III. Información de productos a divulgarse al público
La descripción de los beneficios de cada producto, los planes de niveles metálicos y la
tabla correspondiente de los copagos, coaseguro y deducibles se divulgarán
simultáneamente, luego de aprobarse, a todos los aseguradores el 1 de septiembre de
2014. La Tabla de Copagos, Coaseguro y Deducibles se debe presentar en el formato
Excel. (Véase el Anejo 9).
IV. Radicaciones por medio de SERFF
A. Toda radicación por medio de SERFF se debe acompañar con un Carta de
Trámite que indique el nombre del asegurador o de la organización de
servicios de salud que hace la radicación, firmada por una persona
autorizada, en cumplimiento con el Artículo 3(a)(1) de la Regla XXIV del
Reglamento del Código de Seguros de Puerto Rico. Las cartas de trámite se
deben anejar usando la sección “Supporting Documentation”.
B. Toda documentación de apoyo se debe incluir en la sección “Supporting
Documentation”, lo cual incluye la evidencia de aprobaciones anteriores, la
tabla de los copagos, coaseguro y deducibles, certificaciones y el memorando
de variables, entre otros.
C. Los formularios que se presenta para aprobación se deben incluir en la
sección “Form Schedule”.
D. Los formularios y los documentos se deben guardar en formato PDF sin
protección, de manera que se pueda realizar una búsqueda en el archivo y se
pueda copiar texto del documento.
E. Toda comunicación se debe incluir en el SERFF como una “Note to Reviewer”
(Nota al Revisor)” o como una “Response Letter (Carta de Respuesta).”
Cualquier otro tipo de comunicación se tendrá por no recibida.
En vista de estas normas nuevas, por la presente se revoca la Carta Normativa Núm.
2011-128-AV, del 12 de julio de 2011.
Se ordena por la presente el cumplimiento estricto con las disposiciones de esta Carta
Normativa.
Cordialmente,
FIRMADA
Ángela Weyne Roig
Comisionada de Seguros
March 2014
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Attachment 1
Puerto Rico
Rate Filing Instruction Manual
March 2014
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Overview
This instruction manual supports implementation of the requirement of Ruling Letter NO. CN-
2014-175-AS. For all ACA compliant products, rates for new products and all rate changes must
be submitted to the OCI for approval.
For all grandfathered products only rate increases must be filed with the OCI. Under Section
2794 of the Public Health Service Act, as amended by Section 1003 of the Federal Patient
Protection and Affordable Care Act (“PPACA”), disability insurers that write medical plans in
Puerto Rico have the obligation to submit to the Office of the Commissioner of Insurance
(“OCI”,”OCS”), for review and approval, any rate increase for non-grandfathered plans where
the average increase is equal to or greater than ten percent (10%) of current rates, effective
September 1, 2011. For Health Service Organizations all rate increases must be submitted to
OCI no matter the amount of the increase. The purpose of this requirement is to allow the OCI
(OCS) to determine whether the proposed rate increase for small group and individual markets is
unreasonable. Rates that are subject to approval by the OCI (OCS) must be submitted at least
sixty (60) days before the effective date.1 If there is an objection from the OCI (OCS), the time
required for the objection to be answered will not be included in the 60 days and therefore may
delay the implementation date.
The carrier MUST only use the rates filed and approved.
A complete rate filing must include all of the information required by Ruling Letter NO. CN-
2014-175-AS, as applicable. The manual and templates do not supersede the regulations, they
merely standardize and make explicit the information already required or allowed to be requested
by those regulations.
Carriers must use SERFF to submit their rate filings as required by Ruling Letter 2012 140-AV
of February 7, 2012. Carriers must fill out all the SERFF data elements, including Affordable
Care Act (“ACA”) data elements, or the filing will be rejected as incomplete. ACA requires that
if there is any rate change to an ACA compliant product, rates for all ACA compliant products in
that market (individual or small group) must be filed together. That is if any rates change all
previously filed rates must be filed again with the new rates.
Under the Affordable Care Act and rules that became effective on 9/1/2011, carriers with
average rate increases of more than 10% per year must submit rate justification information to
the Federal Center for Consumer Information and Insurance Oversight (“CCIIO”). For non-
ACA compliant products2, the federal rate summary worksheet and Preliminary Justification also
should be submitted to the Centers for Medicare & Medicaid Services (“CMS”) on the same date
as the filing with the OCI (OCS). Please note that the information submitted to the OCI (OCS)
should be consistent with the information submitted to the “CCIIO” and “CMS.” In Puerto Rico,
all rate increases by HMOs must be filed with the OCI (OCS) if they are ACA compliant or not.
1 To ensure that rates are approved before they are effective the OCI is requesting that all rates be filed 90 days
before they are used. This will be May 30, 2014 for rate filings for 2015 rates.
2 Non-ACA compliant policies include grandfathered policies and transitional policies.
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Consistent with ACA, the OCI (OCS) requires rate filings to include the following parts, if there
is any change in rates or plans offering of ACA compliant products in a market. For all ACA
compliant products the following should be filed once a year even if there is no rate change. For
ACA compliant products and all grandfathered HMO rate increases and non-HMO rate increases
over 10% should also submit the following:
1) Federal Rate Review Justification Part I: Unified Rate Review Template (URRT);
2) Public form of the rate filing information to be placed on the OCI (OCS) website and
used for the HIOS Federal Rate Review Justification Part II: Written explanation of any
rate increase that is 10% or over;
3) Actuarial Memorandum meeting the requirements of Puerto Rico and the federal 2014
Actuarial Memorandum and Certification Instructions 2.0 (Part III).
4) Puerto Rico actuarial certification;
5) Actuarial value calculator screenshots (for ACA compliant only);
6) SERFF Rate template;
7) Rate manual
8) Puerto Rico Benefits Map (if different from the Benefits Map already filed with the OCI
(OCS) or not Benefits Map has been filed; and
9) Rate filing checklist (see Appendix A: Rate Filing Checklist).
Section I: Unified Rate Review Template (URRT)
Provide a copy of the URRT template in Excel and also in a PDF printout version. The URRT
should be completed with all HIOS information.
For a more complete description of the items in the URRT, please refer to the Department of
Health and Human Services (HHS) instructions.
Section II: Written Explanation
For all rate increases that are greater than the review threshold, a brief written explanation of the
rate increase must be submitted. This written explanation must include a simple and brief
narrative describing the data and assumptions that were used to develop the rate increase. This
includes:
1) Brief description in simple language the reasons why the rate increase is being requested;
2) Explanation of the most significant factors causing the rate increase, including a brief
description of the relevant claims and non-claims expense increase reported in the rate
increase summary; and
3) Brief description of the overall experience of the policy, including historical and
projected expenses, and loss ratios.
This summary will be uploaded to the OCI website for public use and it will also be used for the
HIOS Preliminary Justification Part II that is required for all rate increases over 10%.
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Section III: Federal Actuarial Memorandum and Certification3
The Actuarial Memorandum and Certification documents the methodology used in developing
the rates and includes an actuarial opinion signed by a qualified actuary providing an opinion
that the rate filing was developed according to actuarial standards and principles and the laws of
Puerto Rico.
A Part III Federal Actuarial Memorandum, including a corresponding actuarial certification,
must be submitted with each Part I Unified Rate Review Template.
The purpose of the Part III actuarial memorandum is to provide support for the values entered
into the Part I Unified Rate Review Template. The documentation should clearly identify the
plans applicable to each piece of information. All assumptions should be adequately justified
with supporting data, where possible, and the rationale for the use of the chosen assumptions.
For a more complete description of the items in the Part III Actuarial Memorandum and
Certification, please refer to the Department of Health and Human Services (HHS) instructions.
Section IV: Puerto Rico Actuarial Memorandum
In order to review rates in Puerto Rico the OCI requires information in addition to the federal
actuarial memorandum. We encourage carriers to submit both the federal information and the
additional Puerto Rico information in the same document. Information that we believe to be in
addition to the federal requirements is italicized below. This difference may change in the future
as the federal requirements change.
The carrier must provide a detailed description of the method used to develop the premium rates.
Since there is much overlap with the Federal Actuarial Memorandum, one actuarial
memorandum can be submitted as long as it contains all of the information required in both
memorandums. The major difference is the Puerto Rico requirements is the addition of
quantitative support for assumptions. The memorandum should also include more detail on any
item that the carrier believes is driving the rate increase projections or would be of particular
concern when reviewing the rate filing.
Overview of Rate Increase
Provide a brief explanation of why a rate increase is being requested and on what policy forms
including the names of the policy forms affected.
Describe the scope and driving factors impacting the rate increase including a description of how
the rates were determined.
Provide a description of:
1) Type of Products;
2) Benefits;
3) General Marketing Method;
3 See Appendix B for Actuarial Certification
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4) Premium Classifications or Rating Factors; and
5) Underwriting Method (grandfathered only).
Rate increase information including:
1) Historic rate increases for the last 3 years;
2) Proposed effective date of the rate increase (grandfathered only);
3) Requested minimum, maximum and average rate increase – from current rates and
annual from one year prior; and
4) Effective through date and any rate increase schedule applicable (small group only).4
Base Period Experience
Provide an explanation of the base period experience used indicating the basis of the data used,
the first incurred date included and the last incurred date included. The last paid date used should
be provided, which indicates the paid through date for the base period experience.
Provide an explanation of how incurred claims were estimated from paid claims including the
average completion factor5 used and an explanation of adjustments made to base period claims
experience.
If contract reserves were established for these contracts, describe what they are for, how they
were developed and how they impacted the rate development.
Describe the treatment of large claims and claims pooling, if any.
Treatment of commercial reinsurance, if any. This is separate from the Transitional Federal
Reinsurance program, but is adjustments for commercial reinsurance purchased by the carrier
to protect against the risk of large claims.
Provide an exhibit showing current age distribution and the age distribution anticipated for
projection period, if different.
Capitation Payments
Describe what is covered by any capitation payments and the PMPM impact.
Projection Factors and Claims Trends
Provide documentation of all assumptions and methodologies used in the development of the
impact of morbidity and enrollee mix.
If there were changes in the benefits covered, provide a description of all benefit changes and
quantitative support of their impact.
4 Small group rate increases can only be on a quarterly basis.
5 The average completion factor is the ratio of the incurred claims for a period of time to the paid claims for the
same period as of the last paid date used for the base period experience. The incurred claims are the total claims
that are expected to be paid in the base experience. The paid claims are the amounts that have actually been paid as
of any point in time. As time goes on more claims are paid and the ratio is higher.
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For each Essential Health Benefit (EHB) not covered previously, the additional cost permember-per-month (PMPM) with an actuarial explanation of how the additional cost was
developed.
Provide a description of all changes in the rating structure, if any, and provide quantitative
support of their impact including all assumptions used.
Provide quantitative support of the impact due to changes to network, if any.
If there are other changes impacting rates, provide a description and quantitative documentation
of all factors, including any adjustments for past experience due to actual loss ratios differing
from target loss ratios.
Provide quantitative documentation of the trend development including as well as an explanation
of the data, assumptions, and periods used.
Provide:
Changes in medical cost trend by major service categories for the past three years and
future projections.
Changes in the use of services by major service categories for the past three years and
future projections.
Historic cost and utilization assumptions used compared to the actual trends experienced. Until
2015 filings for the 2016 rates, there may be little or no information, but starting in 2015 you
should provide the past projections compared to the actual experience.
Please explain significant changes in assumptions from the prior filing assumptions.
Manual Rate Development
If the experience for the product is too small to be considered credible, alternative claims
experience can be used. Include detail description of all alternative experience data used and
how it was adjusted to be appropriate for the market including any adjustments similar in type to
the adjustments made to base data.
Credibility
Indicate the credibility methodology and credibility level of the base period experience.
Paid to Allowed Ratio
Provide a quantitative demonstration of the development of the paid to allowed ratio.6 Since
Puerto Rico has different claims distribution patterns than those used as the basis of the AVC, it
has been determined that company specific projections, which will not be similar to the AVC
outputs, should be used for Puerto Rico rate development and in the URRT Market Experience
worksheet cell V33. 7
6 This ratio is actually the incurred claims to allowed claims ratio
7 The AVC should be used for the determination of metal levels unless it is replaced by a Puerto Rico specific
calculator
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Risk Adjustment and Reinsurance
Risk adjustment and reinsurance do not apply to Puerto Rico.
Non-Benefit Expense Projections
The methodology used to project non-benefit expenses, including gain/loss margins, should be
explained. If a loss ratio approach was used, the carrier should explain how the target loss ratio
was developed.
Administrative Costs
Identify the main factors that affect changes in administrative costs. Discuss how changes in
projected administrative costs and profit are impacting the rate increase and what is driving
these changes.
If budgets were used, the carrier should explain when the budgets were developed and for what
time period.
Provide actual administrative expenses PMPM for the last three years and explain any
significant changes in administrative expenses from the prior filing.
Provide a breakdown of projected administrative expenses with any marketing, commission, and
quality improvement costs separated. If there are no quality improvement costs in the
administrative costs, indicate zero.
If administrative expenses vary by plan explain why.
Projected Gain/Loss Margins
Provide an explanation of how the projected gain/loss margins were developed and any changes
from prior filings.
Taxes and Fees
Provide a description of applicable taxes and fees, their impacts, and an explanation of how they
were allocated across plans.
Provide a breakdown of projected taxes with amounts of each and their quantitative
development.
Medical Loss Ratio
Describe how the projected federal medical loss ratio was calculated. Describe how the
credibility adjustment was determined. A demonstration of the projected loss ratio using the
federal loss ratio formula should be provided including the values used.
If the loss ratio is less than the federal rebate requirement, explain the plan to xomply with the
Federal MLR requirement.
Index Rate
This documentation should provide a descriptive and quantitative development of the plan index
rates starting with the market index. This development should be supported by excel exhibits
with formulas intact. The following steps should be explicit:
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1) Plan level adjustments
a. Projected ratio of incurred claims to allowed claims (pricing actuarial value) for
each plan and any adjustment to utilization due to cost sharing (separate, if
possible);
b. Provider network, delivery system and utilization management adjustment;
c. Benefits in addition to EHBs (the estimate of these benefits should be shown in a
quantitative development);
d. Impact of the eligibility for the catastrophic plan; and
e. Administrative costs.
2) Calibration for base characteristics to base market allowed:
a. Weighted average age;8
b. Calibration for family composition;9, and
c. Calibration for tobacco usage.10
Provide quantitative documentation of the rating factor for tobacco.
Provide an example procedure of determining a family rate. Demonstrate that this family rating
complies with the federal rating rules of the ACA.
AV Metal Values
The AV Metal Values must be determined using the Federal Actuarial Value Calculator. If an alternative
methodology was used due to a unique plan design, it must be well documented.
Plan Adjusted Index Rate
Provide quantitative development in excel with all formulas of the plan adjusted index rate. This
development should start with the market index rate and show all adjustments in the development of the
plan adjusted index rate. The plan adjusted index rate divided by the average age factor should result in
the plan base rate (age 21 non-tobacco rate).
Membership
Provide documentation of all assumptions used to project membership and provide support for those
assumptions.
Company Financial Condition
Describe the financial situation of the company, including surplus, if any. Provide 5 years of
RBC ratio levels.
8 The federal instructions only ask for a weighted average age, but we are requesting the calibration factor, which
is typically the inverse of the weighted average age factor.
9 This calibration is for the situation where there are more than three children, but only three can be included in
the premium.
10 At this time we believe that the federal instructions will be to add this calibration to the actuarial value
adjustment, but we would like to see it separated out.
March 2014
9
Provide historic loss ratios for the last five years.
Small Groups Affected
The carrier should provide a list of all small groups affected by the proposed rate increase, the
proposed increase for each group, the date of the group’s contract renewal, and the effective
date for each group 30 days prior to implementation. The list of small groups affected and
renewal dates will depend on the proposed effective date of the rate increase. The carrier should
list all small groups that will receive a rate increase in the next 30 day period with each group’s
average rate increase, renewal date and rate increase effective date in an Excel file attached to
an email to the OCI. This information will eventually be posted to the OCI website.
Section V: Public Information
Every carrier must provide a written summary of the rate filing to be displayed on the OCI
(OCS) public website. For rate increases over 10% this will also serve as the Preliminary
Justification Part II that should be uploaded to HIOS.
Section VI: Rate Template
Provide the federal SERFF Rates Template in excel. This may need to be uploaded in a zip file if
they are too large to upload to SERFF.
Section VII: Benefits Map and Actuarial Value
Every carrier should provide to the OCI a benefits map which shows, for all plans, all benefits
covered and their respective cost sharing amounts and limits. If the benefits map for a plan has
not changed from the prior filing, it does not need to be resubmitted. The carrier should submit a
list of plans with an indication of which Benefits Maps are included and the date submitted for
any that were submitted previously.
Also for all plans, screenshots of the federal Actuarial Value Calculator (AVC) populated with
plan cost share information should be submitted. If the plan has a unique plan design that does
not work with the federal Actuarial Value Calculator, a certification of unique plan should be
submitted to the OCI as well as quantitative documentation of all adjustments and explanation of
all differences that could not be accommodated using the AVC . If the plan decides not to use the
AVC, they should provide a certification of unique plan design, an explanation of why they did
not use the AVC, and quantitative support for the calculation of each plan’s actuarial value.
If several plans are offered at the same metal level in the same region, the sponsor should
provide further information on them describing what differentiates them and what the target
market is for each.
Section VIII: Rate Manual
If the rate manual has changed or if a carrier has a new product, it should file the rate manual
with the OCI.
March 2014
10
Appendix A - Rate Filing Checklist
Carrier Name:
Date of Initial Filing:
Is this Original or Replacement:
NAIC Company Code:
SERFF Tracking Number:
Market:
For OCI Use Only
Item
File name and
page or
worksheet
Carrier verified
complete filing
(initial)
Complies
Does not
Comply
Comments
Unified Rate Review Template (Excel and PDF)
Public Form of the Rate Filing Information to be
Placed on the OCI website (For Increases Greater
than 10% this will be the Preliminary Justification
Part II)
Brief description in simple language the reasons why the
rate increase is being requested.
Explanation of the most significant factors causing the
rate increase, including a brief description of the relevant
claims and non-claims expense increases reported in the
rate increase summary
Brief description of the overall experience of the policy,
including historical and projected expenses, and loss
ratios.
Actuarial Memorandum meeting the requirements
of Puerto Rico and the Federal 2014 Actuarial
Memorandum and Certification Instructions 2.0
(Part III)
General Information
Company legal name
HIOS issuer ID
March 2014
11
Market
Effective date
Primary contact name, telephone number, email address
Overview of Rate Increase
Provide a brief explanation of why a rate increase is being
requested and on what policy forms including the names
of the policy forms affected.
Describe the scope and driving factors impacting the rate
increase including a description of how the rates were
determined.
Overview of products. This should be a description of
type of products, benefits, marketing method, premium
classifications, renewability, and underwriting method.
Historical rate increase for last 3 years.
Rate increase detailed information such as averages,
minimum and maximum
Effective through date and any rate increase schedule
applicable (small group only)
Include all products which are part of the single risk pool,
including those with no proposed rate adjustment
Base Period Experience
Explanation of the base period used indicating the basis
of the data used, first and last incurred date included.
Indicate paid through date
Provide support for the development of the actuary's best
estimate of allowed and paid claims incurred during the
experience period
Describe the treatment of large claims and claims
pooling, if any.
Treatment of commercial reinsurance, if any. This is
separate from the Transitional Federal Reinsurance
program, but is adjustments for commercial reinsurance
purchased by the carrier to protect against the risk of
large claims.
Indicate the amount of MLR rebates refunded during
experience period
March 2014
12
Exhibit showing current age distribution with those
anticipated for projection period
Capitation Payments
Describe what is covered by any capitation payments.
Projection Factors
Provide documentation of all assumptions and
methodologies used in the development of the impact of
morbidity and enrollee mix.
If there were changes in the benefits covered, provide a
description of all benefit changes and quantitative support
of their impact.
For each Essential Health Benefit (EHB) not covered
previously, the additional cost per-member-per-month
(PMPM) with an actuarial explanation of how the
additional cost was developed.
For adjustment factors related to differences in
demographics, if applicable, include a description of the
source data or assumptions used, why they are
appropriate for the single risk pool, and any applicable
adjustments made to the data, such as considerations for
issuer specific experience, industry or internal studies,
benefit design and credibility.
If there are other changes impacting rates, provide a
description and quantitative documentation of all factors.
Provide a description of all changes in the rating
structure, if any, and provide quantitative support of their
impact including all assumptions used.
Provide quantitative support of the impact due to changes
to network, if any.
Provide quantitative documentation of the trend
development including as well as an explanation of the
data, assumptions, and periods used.
Changes in medical cost trend by major service categories
for the past three years and future projections.
Changes in the use of services by major service
categories for the past three years and future projections.
Please explain significant changes from the prior filing
assumptions.
March 2014
13
Manual Rate Development, if applicable
Describe the source data used to develop the manual rate
and why such data is appropriate.
Describe all adjustments made to the data underlying the
development of the manual rate to account for differences
in demographics, benefits and morbidity/risk to ensure
that that resulting manual rate is appropriate for blending
with the adjusted experience period claims.
Credibility
Indicate the credibility methodology and credibility level
of the base period experience.
Paid to Allowed Ratio
Provide a quantitative demonstration of the development
of the paid to allowed ratio based on company specific
projections.
Non-Benefit Expense Projections
Administrative Costs
The methodology used to project administrative
expenses, including gain/loss margins, should be
explained.
Identify the main factors that affect changes in
administrative costs. Discuss how changes in projected
administrative costs are impacting the rate increase and
what is driving these changes.
Actual administrative expenses PMPM for the last three
years and explain any changes in administrative expenses
from the prior filings.
Breakdown of projected administrative expenses with any
quality improvement costs separated.
Discuss how and why the percentage administrative load
varies by product or plan, if applicable
Projected Gain/Loss Margins
Describe the target underwriting gain/loss margin, and
any additional risk margin
To the extent that the target as a percent of premium has
changed from the prior submission, provide additional
support for why the change is warranted
March 2014
14
Discuss how the percentage load varies by product or
plan, if applicable
Taxes and Fees
Describe each tax and/or fee and indicate the amount for
each, either as a percent of premium or a PMPM amount
and a quantitative development.
Provide an explanation of how taxes and fees were
allocated across plans.
Medical Loss Ratio
Provide a demonstration of the projected loss ratio using
the federal rebate loss ratio formula including the values
used.
Describe how the credibility adjustment was determined,
if applicable.
If the projected loss ratio is less than federal requirement,
explain the plan to comply with the Federal MLR
requirement.
Index Rate
Demonstrate in Excel with formulas how the projected
market level index rate was adjusted to arrive at each plan
level index rate.
Provide an example procedure of determining a family
rate. Demonstrate that this family rating complies with
the federal rating rules of the ACA.
For the catastrophic plan rate, describe the methodology
used to estimate the adjustment reflecting differences in
anticipated demographics and morbidity of the
catastrophic population as compared to the single risk
pool
AV Metal Values
The issuer must describe whether the AV Metal Values
included were entirely based on the AV Calculator, or
whether an acceptable alternative methodology was used
to generate the AV Metal Value of one or more plans
If an alternate methodology was employed to develop the
AV Metal Value(s), the actuary must provide a copy of
the actuarial certification required by 45 CFR Part 156,
§156.135
March 2014
15
Provide all AVC screen shots
Plan-Adjusted Index Rate
Quantitative development in Excel (with working
formulas) of the plan-adjusted index rates starting with
the market index rate.
Membership Projections
Describe how the membership projections were
developed
Describe any differences between the distribution of
projected member months relative to the current
membership distribution
Company Financial Condition
Describe the financial situation of the company, including
surplus, if any. Provide 5 years of RBC ratio levels.
Provide historic loss ratios.
Terminated Products
List the name of each product that will be terminated
prior to the effective date including other products that
have experience included in the single risk pool during
the experience period and any products that were not in
effect during the experience but were made available
thereafter
Plan Type
In the event that the plan types listed in the drop-down
box in Worksheet 2, Section I of the Part I Unified Rate
Review Template do not describe an issuer’s plan exactly
and the issuer has selected the closest plan available, per
the instructions, please describe the differences between
the issuer’s plan and the plan type selected.
Warning Alerts
Describe any difference between the sum of the plan level
projections and the total projected amounts
Reliance
If the certifying actuary relied on any information or
underlying assumptions provided by another individual,
the information relied upon and the name of the
March 2014
16
individual providing that information may be disclosed.
For All Small Groups Affected
Name of group
Group's average rate increase
Date of contract renewal
Effective date of rate increase
Federal Actuarial Certification
Puerto Rico Certification Letter
SERFF Rates Template (Excel)
Rating Manual (if filed previously indicate date
filed)
Puerto Rico Benefits Maps for each plan (if filed
previously indicate date filed)
COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
B5 Tabonuco Street, Suite 216 • PMB 356 • Guaynabo, PR 00968-3029
Phone: (787) 304-8686 • Fax: (787) 273-6082
www.ocs.gobierno.pr
17
Appendix B – Standardized Actuarial Certification Letter
Certification
Standardized Excel Worksheet/Written Filing Documentation/Rate Manual
I _________________________________________ hereby certify that I was in charge of the preparation, revision or supervision of the
worksheet data information corresponding to the submitted rate increase filing. In addition, I certify that the submitted information is
accurate, true and complete.
I also acknowledge responsibility for the validity, accuracy and completeness of the contents of the Written Filing Documentation and the
Rate Manual.
______________________________
Signature
______________________________
Title
______________________________
Carrier
______________________________
Date
1
Attachment 2
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-15
Baltimore, Maryland 21244-1850
Part I Unified Rate Review Template Instructions
February 3, 2014
2
Part I Unified Rate Review Template v2.0.1
The Part I Unified Rate Review template is required to be submitted by all issuers in the
individual, small group and/or combined markets that are proposing a rate increase on any
single risk pool compliant products. In addition, all issuers applying to offer at least one QHP in
the state must submit the template for the market in which the QHP would be offered. The
template may also be required by regulatory authority for products in the single risk pool.
Issuers are required to submit the annual rate change (i.e. January rate changes). In addition,
quarterly rate increases for the small group market are allowed if allowed by the state
regulatory authority. See the Appendix for additional detail on the timeframe for submission.
All issuers are required to set the Index Rate for an effective date of January 1 of each year, and
file the Index Rate with the applicable regulatory authority. Subject to state requirements, small
group issuers are allowed to file subsequent submissions that reset the Index Rate for the
remaining quarters of the calendar year.
The Part I Unified Rate Review template is intended to:
• Demonstrate compliance with the Single Risk Pool requirement of 45 CFR Part 156.80,
• Provide support for the development of the Index Rate which is defined in 45 CFR Part
156.80(d),
• Identify product level rate increases to determine whether a rate increase is subject to
review under 45 CFR Part 154, and
• Provide supporting information to State or Federal regulators for product level rate
increases
Additional information about how CCIIO uses or discloses information from the template is
described in the Appendix.
Specific instructions for the treatment of dental plans within the Part I Unified Rate Review
template have been developed for plans offered in 2015 and beyond.
• Only embedded pediatric dental benefits within a medical plan should be reflected in
the Part I Unified Rate Review Template. Further, in order for the dental costs to be
included in the Part I Unified Rate Review Template the dental costs must be spread
across the entire single risk pool in accordance with the market rating rules in
calculating the projected Index Rate.
3
• Under no circumstances should stand‐alone dental plans be reflected in the Part I
Unified Rate Review Template.
Further details explaining how dental plans should be reflected in the template can be found in
the instructions for Worksheet 2.
Beginning with plans effective in 2015 and beyond, ALL benefits to be offered in a plan must be
included in that plan. So if an issuer wants to offer an “optional” benefit, there are two options
an issuer can use to meet this goal.
• The issuer can create a separate plan with the required EHBs and the “optional” benefit
included.
• The issuer can offer a separate policy which is a supplemental policy providing non‐EHB
benefits.
The concept of “optional riders” is incongruent with federal rating rules and the single risk pool
requirements.
It is critically important that information be entered into the template as accurately as possible
with the information available to the issuer at the time of submission. Failure to provide
accurate information in the first submission increases the likelihood of the need to provide
additional data to the State or Federal regulators reviewing the template. Failure to provide
accurate information also slows the speed of any required approvals or certification and puts
the products and plans at risk for missing critical deadlines to be offered in the markets.
Beware, if an issuer copies and pastes values into cells that do not match the formatting
requirements of those cells, the mismatch may cause validation or submission errors resulting
in either submissions being rejected or requiring resubmissions at a later date. Issuers should
verify the data entered in the Part I Unified Rate Review Template is consistent with formatting
requirements and instructions to avoid delays in the approval process.
Under no circumstances should issuers attempt to overwrite protected cells. For example, the
totals in column F of Worksheet 2 are protected and calculated by formula. Issuers should not
attempt to overwrite the values calculated by the template. Any overwriting of the workbook’s
protection is likely to result in delays and resubmissions.
The following should be considered an instructional tool in developing issuer pricing, as allowed
under the market and rating rules for the single risk pool.
ACA & MARKET RATING RULES ‐ ALLOWABLE RATING & PRICING
Allowable rating methods and factors
4
• The Single Risk Pool should include ALL (non‐grandfathered) covered persons (lives) an
issuer has in a state, within a market (individual, small group or combined). This
includes transitional products/plans for purposes of base period experience used to
demonstrate the single risk pool. The projection period should reflect experience of
transitional policies to the extent the issuer anticipates the members in those policies
will be enrolled in fully ACA‐compliant plans during the projection period.
• The Index Rate is defined as the EHB portion of projected allowed claims divided by all
projected single risk pool lives. As a result, the Index Rate should be the same value for
ALL non‐grandfathered plans for an issuer in a state and market. This includes claims
and enrollment in transitional products/plans in the experience period, and in the
projection period to the extent the issuer anticipates the members in those policies will
be enrolled in fully ACA‐compliant plans during the projection period. Note that if an
issuer opted to continue policies under the President’s transitional memorandum,
experience for these policies should be included in the issuer’s 2013 experience for
developing rates for the 2015 year. Appropriate adjustments should be made in
Worksheet 1 – Section II of the Unified Rate Review Template to bring these policies in
line with all requirements of non‐grandfathered policies projected in the Single Risk Pool
in 2015. For example, in the projection period, include projected experience and
membership at the point when these products become ACA‐compliant and the
membership renews to the ACA‐compliant plan, or at the point when the members in
these plans move to an ACA‐compliant plan, if the plans are closed to new membership
in 2015.
• The Market Adjusted Index Rate is the Index Rate adjusted for Risk Adjustment,
Reinsurance and Exchange Fees (with impacts and costs spread across the whole risk
pool). As a result, the Market Adjusted Index Rate should be the same value for ALL
non‐grandfathered plans for an issuer in a state and market.
• The Plan Adjusted Index Rate is the Market Adjusted Index Rate further adjusted for
plan specific factors allowed by 45 CFR Part 156.80(d)(2) such as provider network,
utilization management, benefits in addition to Essential Health Benefits (EHBs),
actuarial value and cost sharing, distribution and administrative costs (less Exchange
fees) and catastrophic plan eligibility variation.
• Note, fees and costs are included in the premium and applied at the plan level as part of
the distribution and administrative costs adjustment. The only exception is the
application of the Exchange User fees, which are applied at the market level to the Index
Rate. All other fees must be included in the development of the Plan Adjusted Index
5
Rate, prior to the application of member level rating factors, such as age factors. No
additional fees may be charged outside of the development of the Plan Adjusted Index
Rate. For example, if it costs an issuer $35 to process an application, that cost must be
included in the premium rate development of all policies (new issues and renewals) and
subject to the member level rating factors such as age and geographic region factors.
The issuer may not, in that example, charge a $35 fee per policy for submission of the
application.
• A calibration may be required to allow the rating factors to be directly applied in order
to generate the Consumer Adjusted Premium Rates.
For each allowable rating factor (i.e. age, geography, and tobacco) there is ONLY ONE
calibration allowed. That is, the calibration from the single risk pool to the allowable
rating factors may not vary by plan; it must be a common adjustment for all plans in a
state and market. The only allowable consumer level premium rate modifiers that can
be calibrated are age, geography and tobacco.
The calibration with respect to the age curve is allowed and identifies the value on the
age curve associated with the weighted average age on the standard age curve. The Plan
Adjusted Index Rate and the age curve can then be used to generate the schedule of
premium rates for all ages for each plan. Calibration may be required for the geographic
factors and tobacco factors. More detailed instructions are provided later in this
document regarding the requirements for the calibration.
It is important to note that the calibration process (described above) should ONLY occur
after the Plan Adjusted Index Rate has been determined, not at any point before. The
cost of all benefits (EHB and non‐EHB) and other expenses may not be charged to the
consumer using a flat dollar amount. All components under the plan must be part of the
premium charged. All components of the premium are subject to the consumer level
rating adjustments and therefore all components of the premium should likewise have
the calibration applied to them.
The result of this calibration process should be that the Plan Adjusted Index Rate
calibrated for geography and tobacco (but not age), multiplied by the geographic factor
for a given region should be similar to the Premium Rate for that particular plan for a
non‐tobacco user in the given geographic region for the weighted average age (rounded
to a whole number) of the projected single risk pool.
• The Consumer Adjusted Premium Rate is the final premium rate for a plan that is
charged to an individual, family, or small employer group utilizing the rating and
premium adjustments as articulated in the applicable Market Reform Rating Rules. The
Consumer Adjusted Premium Rate is developed by calibrating the Plan Adjusted Index
Rate to the age curve as described above, calibrating for geography and tobacco if
6
necessary, and applying the allowable rating factors. Allowable rating factors are Age
(3:1 standard age curve or state specific age curve), Tobacco, Geography and Family
tiering/structure, unless otherwise prohibited by state law.
Once the Plan Adjusted Index Rate is calibrated to the age curve using the weighted
average age, the entire set of age rates is determined using the standard age factor of
each age relative to the standard age factor for the rounded weighted average age. The
age factors must be the standard age curve set by HHS or a state specific age curve (if
the state requires different age factors than the standard federal age curve).
The tobacco factors can be issuer specific but cannot vary by product/plan for an issuer
(i.e. an issuer must use the same tobacco factors across all products/plans within a state
and market).
Geographic rating areas are set specific to each state and all issuers in the state are
required to follow them and may only set one rating factor per rating area per state per
market and that factor is applied to all plans the issuer has in that rating area
uniformly. If an issuer has multiple networks within a given rating area and wants to
develop premiums specific for each network, the issuer must have a separate plan for
each network with the rating area.
Family structure takes into account family composition and the maximum of 3 child
dependents. This is further clarified in regulation that the premium for family coverage
is determined by summing the premiums for each individual family member, provided
at most three child dependents under age 21 are taken into account; this adjustment
does not result in a separate rating factor. Family tiering only occurs in states that use
pure community rating and are uniformly applied to all plans in the risk pool (and
published to the cciio.cms.gov website).
Worksheet 1 – Market Experience
The purpose of Worksheet 1 is to capture information at the market level for non‐
grandfathered products, consistent with the requirement to set premium rates using a single
risk pool, as defined in 45 CFR Part 156, §156.80. The worksheet is not intended to prescribe a
rate development methodology. Rather, the worksheet captures experience period data and
key assumptions consistent with those used in the development of the proposed premium rate
increases. The worksheet uses the data to show that the average gross premium rate complies
with the requirements of the single risk pool, and reports the total and annualized change in
the gross premium relative to the experience period. These calculated changes in the average
premium are not equal to the average rate increase of the pool, but rather provide information
7
on how the average gross premiums have changed over time. There are four sections in this
worksheet.
• The General Information section captures information about the issuer, state and the
health insurance market to which the proposed rate increases will apply. This
information is displayed on all worksheets of the Part I Unified Rate Review Template.
• Section I captures summarized historical financial and enrollment information from a
recent historical experience period.
• Section II captures historical claims experience on a more granular level, along with the
key assumptions employed to project the experience period information forward to the
projection period of the effective date.
• Section III displays the assumptions used to adjust the projected allowed claims to
incurred claims at the average anticipated benefit level. Administrative expense loads
and risk/profit charge loads are also captured. Using this information, the average gross
premium for the single risk pool is generated.
General Information
Company Legal Name: Enter the organization’s legal entity name.
The name entered in this cell must be the name that is associated with the HIOS Issuer
ID.
State: Enter the state that has regulatory authority over the policies. A separate template must
be completed for each state in which the issuer is applying for QHP certification or proposing a
rate increase on non‐grandfathered policies in the individual, small group or combined markets.
HIOS Issuer ID: Enter the HIOS ID assigned to the legal entity.
Market: Select the applicable market from the drop‐down box. Valid markets are Individual,
Small Group, or Combined.
The market chosen must be consistent with the state’s determination of their allowable
markets (e.g. if a state chooses to merge the individual and small group market, the
issuer must choose “Combined”).
Effective Date: Enter the effective date for which rates are being submitted.
If the submission is for the individual or combined markets, the effective date must be
January 1 of the year for which rates are being submitted. If the submission is for the
small group market, enter the effective date for which the Index Rate is being revised.
For example, if the small group submission revises the Index Rate for July 1, 2015
8
effective dates and includes a trend increase applicable on October 1, 2015, enter July 1,
2015. See the Appendix for further guidance on trend increases in the small group
market.
All issuers are required to file the Part I Unified Rate Review Template and Part III Actuarial
Memorandum annually for an effective date of January 1 of each year. Subject to state
requirements, small group issuers are allowed to file subsequent submissions that reset the
Index Rate for the remainder of the calendar year. However, the change in the Index Rate is
only allowed to occur for the remainder of the calendar year and subsequent submission is
required for the beginning of the next calendar year.
For example, if a small group issuer submits the Part I Unified Rate Review Template for
January 1, they may submit a subsequent Part I Unified Rate Review Template that
resets the Index Rate effective July 1 of that same year. The Part I Unified Rate Review
Template effective July 1 in this example is only allowed to contain a trend increase for
October 1 of that same year. Quarters after October 1 would be included in the next
annual submission effective January 1 of the next calendar year.
All products and plans must have the same effective date; however, some products or
plans may have a 0% rate change. The term “product” is defined as a unique
combination of benefits, various cost sharing options and a network design(s) to a
particular service area. “Product” has the same meaning as included in 45 CFR Part 154.
The term “plan” is defined as a unique combination of benefits to a specific set of cost
sharing options and network design(s) to a particular service area. Most products will
be made up of multiple plans produce an actuarial value equal to one of the metal levels
permitted under Title I of the Patient Protection and Affordable Care Act, as amended
by the Health Care and Education Reconciliation Act of 2010, collectively referred to as
the Affordable Care Act (ACA).
Section I
The financial and enrollment information entered in this section should reflect the experience
of all non‐grandfathered policies for the specified market and state. The information is
intended to reflect the single risk pool for the market as required by the ACA and 45 CFR
156.80. The information in this section should reflect historical financial and enrollment
information for the identified legal entity only.
Experience Period: Enter the first date of the experience period.
The Experience Period must be a twelve month period. The template calculates the end
date of the experience period such that the period is twelve months long.
9
For individual and combined market submissions, the Experience Period must be a
calendar year period. It should be the most recently completed calendar year; if not,
include an explanation in the Part III Actuarial Memorandum. Therefore, the first date of
the Experience Period must be January 1. For small group market submissions, the first
date of the Experience Period must be the first date of a calendar quarter, i.e., January
1, April 1, July 1, or October 1.
If an experience period other than that required to be shown is used in the derivation of
the Index Rate, then the credibility manual rate section should be used to show the
Index Rate development and described in the Part III Actuarial Memorandum.
The Experience Period reflects a period during which premiums were earned and claims
were incurred. For example, if the Experience Period is January 1, 2012 through
December 31, 2012 the issuer may include claims payments through a date beyond the
end of the experience with dates of service within the Experience Period (e.g., February
28, 2013) when estimating the total claims incurred during the period. The paid through
date is not captured in the template, but is requested in the Part III Actuarial
Memorandum.
Premiums (net of MLR Rebate) in Experience Period: Enter the amount of premium earned
during the experience period, net of rebates to policyholders on an incurred basis due to the
medical loss ratio (MLR) requirements as defined in 45 CFR Part 158.
Start with premiums earned during the experience period. Subtract the actual or
estimated MLR rebates incurred during the experience period.
Enter the aggregate net premium dollars earned. The template will calculate the per
member per month (PMPM) premium amount and the percent of premium.
Do not subtract amounts from the net earned premium that would be subtracted from
earned premium in the denominator of the MLR calculation, such as taxes and fees. For
portions of the experience period for which the MLR rebate has not been finalized,
include a best estimate of the rebates in the reported net premium. See the Part III
Actuarial Memorandum instructions for required documentation of the method used to
estimate rebates.
Incurred Claims in Experience Period: Enter total claims incurred in the Experience Period.
Enter the aggregate incurred claims. The template calculates the PMPM incurred claims
amount and the incurred claims as a percent of premium. The calculated percent of
premium attributable to claims is not equivalent to the MLR, and therefore may be less
than 80%.
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Incurred claims are defined as allowed claims (defined immediately below) less member
cost sharing and cost sharing paid by HHS on behalf of low‐income members.
Member cost sharing is defined as payments made against the allowed claims by the
member for health care services (e.g., deductible, coinsurance and copayments). This
does not include premium or the amount of billed charges the member must pay in
excess of the issuer’s contractual allowed amount (often described as “balance billing”).
Allowed Claims: Enter total allowed claims with dates of service during the Experience Period.
Allowed Claims are defined as the total payments made under the policy to healthcare
providers on behalf of covered members, and include payments made by the issuer,
member cost sharing, and cost sharing paid by HHS on behalf of low‐income members.
Consequently, they include actual payments made or estimates of costs incurred but not
yet paid during the period. See Part III of the Actuarial Memorandum instructions for
guidance related to incurred but not paid claim reserve documentation. They also
include claims not tied to a specific date of service, such as capitation or risk sharing
payments, if the payments were for services provided during the Experience Period.
They include claims for essential health benefits (EHB) as well as benefits other than
EHB. This would not include the amount of billed charges the member must pay in
excess of the issuer’s contractual allowed amount (often described as “balance billing”).
By definition, “Allowed Claims” do not include:
• Ineligible claims such as duplicate claims, third party liabilities (e.g. coordination
of benefits claims), and any other claims that are denied under the policy terms.
• Payments for services other than medical care provided, (e.g., medical
management, quality improvement, and fraud detection and recovery expenses)
even if these amounts are included in claims for MLR reporting purposes.
• Recovery payments the issuer may receive from private reinsurance or internal
large claim pooling mechanisms. These types of adjustments should be handled
in the Other adjustment factor found in Section II of Worksheet 1.
• Active life reserves (policy reserves, contract reserves, contingency reserves, or
any kind of reserves except traditionally defined reserves for claims incurred but
not paid) or change in such reserves.
Index Rate of Experience Period: Enter the Index Rate underlying the Experience Period. The
value entered in this field must be a whole dollar value (i.e. the rate must be rounded to the
nearest $1). Please note, if an issuer copies and pastes a value in this cell which contains
decimals, the Part I Unified Rate Review Template submission could be rejected or an issuer
11
may be required to make a resubmission later in the process which could delay the rate review
process and approval.
The Index Rate represents the average allowed claims PMPM for essential health
benefits. It is the legal entity‐specific rate for the market that is being submitted – i.e.,
the issuer’s individual market, small group market or combined market. It should not be
adjusted for payments and charges under the risk adjustment and reinsurance programs
or for Exchange user fees. It is simply allowed claims PMPM for essential health
benefits.
The Index Rate should be developed using all covered members, even if premium was
not explicitly collected for all members. For example, if the number of members in a
given family or policy was capped for premium setting purposes either voluntarily by the
issuer or as required by law, all family members covered by the policy should be
included.
The experience period Index Rate should be adjusted to exclude benefits that are in
excess of essential health benefits, but should not be adjusted to include essential
health benefits that were not covered during the experience period, such as, in some
cases, maternity coverage in the individual market.
Experience Period Member Months: Enter the total number of months of coverage in the
Experience Period for all members that had coverage during any portion of the Experience
Period.
For example, if a given member had coverage for five months during the Experience
Period, that member would contribute five member months to the total member
months for the period. The number entered must be an integer. For partial months,
issuers should define a methodology for counting partial months and apply the
methodology consistently to all members. Possible methodologies include but are not
limited to rounding up, rounding down, rounding to nearest, counting the member
month if the member is active on the 15th of the month, etc.
Include all covered members even if premium was not explicitly collected for all
members. For example, if the number of members in a given family or policy was
capped for premium setting purposes either voluntarily by the issuer or as required by
law.
Section II: Allowed Claims, PMPM basis
Projection Period: The projection period is determined by the template. The Projection Period
starts on the effective date entered in the General Information section of the template. The
Projection Period end date is calculated such that the Projection Period is a twelve month
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period. The template also calculates the number of months between the midpoint of the
Experience Period and the midpoint of the Projection Period.
Benefit Category
Several fields that follow require issuers to enter data by Benefit Category. Issuers are required
to describe the Benefit Category definitions in the Part III Actuarial Memorandum. The
preferred definitions of the Benefit Category follow:
Inpatient Hospital: Includes non‐capitated facility services for medical, surgical, maternity,
mental health and substance abuse, skilled nursing, and other services provided in an inpatient
facility setting and billed by the facility.
Outpatient Hospital: Includes non‐capitated facility services for surgery, emergency room, lab,
radiology, therapy, observation and other services provided in an outpatient facility setting and
billed by the facility.
Professional: Includes non‐capitated primary care, specialist, therapy, the professional
component of laboratory and radiology, and other professional services, other than hospital
based professionals whose payments are included in facility fees.
Other Medical: Includes non‐capitated ambulance, home health care, DME, prosthetics,
supplies, vision exams, dental services and other services.
Capitation: Includes all services provided under one or more capitated arrangements.
Prescription Drug: Includes drugs dispensed by a pharmacy. This amount should be net of
rebates received from drug manufacturers.
Experience Period on Actual Experience Allowed
The experience entered in this section needs to reflect the state and market identified in the
General Information section and the Experience Period identified in Section I of this worksheet.
The actual experience for this period, state and market should be entered in the template,
regardless of the credibility level.
Utilization Description: For each Benefit Category, choose the appropriate measurement unit
that reflects the utilization per 1,000 covered members per year from the drop down menu.
Valid entries are shown below.
Admits (for Inpatient service category only)
Days (for Inpatient service category only)
Benefit Period (for Capitation service category only)
Visits
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Services
Prescriptions (for Prescription Drug service category only)
Other
In cases where “Other” is selected provide additional descriptions of the measurement
units in the Part III Actuarial Memorandum.
Utilization per 1,000: Enter the total utilization per 1,000 covered members per year for claims
incurred during the Experience Period.
The utilization must be entered on an annualized basis. Include any necessary estimates
of utilization related to claims incurred but not yet paid.
Average Cost/Service: Enter the average allowed cost per unit of service for claims incurred
during the Experience Period.
While not required, issuers may adjust the average cost per service for claims incurred
but not yet paid if the issuer estimates the claims not yet paid to have a different
average cost per service than those already paid. If an adjustment is made it should be
described in the Part III Actuarial Memorandum.
PMPM: The Allowed Claims PMPM is calculated by the template, and is equal to utilization per
1,000 times average cost per service, divided by 12,000. The template sums the PMPM from
each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the
Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.
Adjustments from Experience to Projection Period
Population risk Morbidity: Enter the assumed change in morbidity of the covered population
from the Experience Period to the Projection Period.
“Change in morbidity” means that component of the change in average allowed claims
PMPM (as described earlier in these instructions) that will occur under the
circumstances where all demographic (e.g., age, gender, and region) and product mix,
all provider network contracts and time parameters (i.e., trends = 0) are held constant
on the population that exists in the Experience Period.
The change in morbidity must be entered as 1 plus the total anticipated percent change
in morbidity from the Experience Period to the Projection Period. For example, if in a 24
month period from the Experience Period to the Projection period the morbidity is
expected to increase by 10%, enter 1.100. Similarly, if the morbidity is expected to
decrease by 10% over the 24 month period, enter 0.900.
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This category may include a number of adjustments since the market rules during the
Projection Period may be significantly different from those in the Experience Period. In
addition, the impact of new market rules is expected to vary significantly state to state.
Some of the adjustments issuers might include are:
• Guarantee issue
• Take‐up rate of the uninsured (the percent of currently uninsured that purchase
coverage during the projection period)
• Health status of newly insured
• Enrollment from prior high risk pools
• Induced demand of newly insured
• Pent‐up demand of newly insured
• Subsidy effects
Expected changes in the demographic mix (e.g. age, gender, and region) and tobacco
status should not be included in this factor. These factors can be included in the “Other”
factor.
A description of the methodology used to develop the adjustment must be included in
the Part III Actuarial Memorandum.
Other: Enter the assumed change in cost related to things other than a change in population
morbidity, cost trend, and utilization trend. Cost trend and utilization trend are defined in the
section immediately following.
The other change must be entered as 1 plus the total anticipated percent change in cost
from the Experience Period to the Projection Period, similar to the Population risk
Morbidity adjustment.
Some of the adjustments an issuer might include in this section are:
• Changes in covered services
• Significant changes in the provider network, such as adding or removing a
provider system, or introducing a limited network option. Shifts in the
distribution of services across existing network providers should be reflected in
the Cost Trend.
• Projected changes in cost related to demographics of the projected covered
population
• Projected changes in pharmacy rebates relative to the pre‐rebate prescription
drug allowed claims
15
• In the event an issuer has capitation in the experience period but does not
expect to have capitation in the projection period, the issuer should enter a
near‐zero value in the “Other” projection factor to remove the costs. It is not
anticipated that other EHB categories would need to remove the experience for
the entire benefit category.
A description of the methodology used to develop the adjustment must be included in
the Part III Actuarial Memorandum.
Annualized Trend Factors
Cost Trend: Enter the assumed change in cost per service from the Experience Period to the
Projection Period.
The Cost Trend must be entered as 1 plus the annualized trend assumption. For
example, if the period from the midpoint of the Experience Period to the midpoint of
the Projection Period is 24 months and if costs in the projection period are expected to
be 10.25% higher than the Experience Period, then the annual trend is 5.0% (√1.1025 ‐
1). In this example, the user should enter 1.050 (√1.1025ሻ.
Include only the increase in cost for a fixed basket of services. Changes in cost related to
changes in mix of services should not be reflected here (they will be reflected in
utilization trend described below). Changes in cost related to a change in the
distribution of services across network providers should be included. Significant changes
in network, such as adding or removing a provider system, or introducing a limited
network option should be reflected in the “Other” adjustment and described in the Part
III Actuarial Memorandum.
Projected changes in prescription drug cost related to manufacturer rebates should be
reflected in the “Other” adjustment.
Utilization Trend: Enter the assumed change in utilization per 1,000 members from the
Experience Period to the Projection Period.
The Utilization Trend must be entered as 1 plus the annualized trend assumption, in the
same manner as the cost trend.
Utilization Trend should include the change in the number of units per 1,000 members
for a fixed level of illness burden. If utilization is expected to increase/decrease due to a
change in the average health status of the population, that change should be reflected
in the Population risk Morbidity adjustment described above.
Utilization Trend should include assumed changes in the mix or intensity of services
provided for a fixed level of illness burden.
16
Utilization Trend should also reflect changes related to shifts in product mix. This
includes changes in induced demand related to product shifts. It also includes any
effects of selection since this cannot be reflected in the relative cost of the various
products and plans offered.
Projections, before credibility Adjustment
Projections before credibility adjustment are calculated by the template.
Utilization per 1,000: The template calculates projected utilization per 1,000 by multiplying the
experience period utilization per 1,000 by the Population risk Morbidity adjustment and the
utilization trend assumption. The Utilization Trend assumption in this calculation is raised to the
power of the number of months between the midpoint of the Experience Period and the
midpoint of the Projection Period (calculated previously by the template), divided by 12.
Average Cost/Service: The template calculates the projected average cost per service by
multiplying the experience period average cost per service by the Other adjustment and the
cost trend assumption. The Cost Trend assumption in this calculation is raised to the power of
the number of months between the midpoint of the Experience Period and the midpoint of the
Projection Period (calculated previously by the template), divided by 12.
PMPM: The projected allowed claims PMPM is calculated by the template, and is equal to
projected Utilization per 1,000 times projected Average Cost/Service, divided by 12,000. The
template sums the PMPM from each Benefit Category to calculate the total PMPM.
Credibility Manual
The credibility manual Utilization per 1,000 and Average Cost /Service need only be populated
with values greater than zero if the experience period claims data is less than 100% credible for
projecting future premium rates. When the experience period claims data is 100% credible
zeros must still be entered in the credibility manual section so as not to produce errors when
the template is validated. While credibility may not be applied in this manner in rate
development, it must be shown in this manner for reporting purposes.
Utilization per 1,000: Enter the assumed utilization per 1,000 for the data underlying the
credibility manual.
The Utilization per 1,000 must reflect the population and covered services for which
rates are being submitted. If the issuer uses another credible block of business as the
credibility manual, for example, the utilization of that population should be adjusted to
reflect morbidity consistent with the projected population. Other adjustments may be
necessary. The source of the credibility manual Utilization per 1,000 and the
adjustments applied to it should be described in the Part III Actuarial Memorandum.
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Average Cost/Service: Enter the assumed average cost per service for the data underlying the
credibility manual.
The cost per service must reflect the projected cost for the population and covered
services for which rates are being submitted. If the issuer uses another credible block of
business from a different geographic region as the credibility manual, for example, the
cost for that population should be adjusted to reflect differences in provider contracting
of the two regions. The source of the credibility manual average cost per service and the
adjustments applied to it should be described in the Part III Actuarial Memorandum.
PMPM: The projected credibility manual PMPM is calculated by the template, and is equal to
the credibility manual Utilization per 1,000 times the credibility manual Average Cost/Service,
divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the
total PMPM.
Section III: Projected Experience
Projected Amounts After Credibility
Credibility Percentage: Enter the assumed level of credibility to be applied to the experience
period claims that have been projected to the rating period.
The percentage must be between 0% and 100%. Describe the methodology used to
determine the Credibility Percentage in the Part III Actuarial Memorandum.
The template calculates the credibility to be assigned to the credibility manual, and is
equal to 1 minus the credibility assigned to the projected experience claims.
Projected Allowed Experience Claims PMPM (w/ applied credibility if applicable): The
template calculates this value as the sum of the projected experience PMPM multiplied by its
credibility, and the credibility manual PMPM multiplied by the complement of the credibility
(calculated previously by the template).
Paid to Allowed Average Factor in the Projection Period: Enter the average paid to allowed
factor for the Projection Period.
This amount is not from the AV calculator. It should equal the total expected paid claims
that are the liability of the issuer divided by the total expected allowed claims for the
Projection Period, for the population anticipated to be covered in the Projection Period.
Allowed claims have the same definition as in Section I. Paid claims are analogous to the
Incurred Claims defined in Section I. Paid claims are net of member cost sharing and cost
sharing paid by HHS on behalf of low‐income members. The Paid to Allowed Average
Factor in the Projection Period should reflect the average benefit level anticipated
during the projection period. For example, if the issuer’s members were enrolled
18
primarily in Silver plans in the experience period, but are anticipated to shift to Bronze,
then the Paid to Allowed Average Factor in the Projection Period should reflect Bronze
cost sharing levels.
Since the paid claims in the numerator are the trended amounts for the Projection
Period, they should reflect any leveraging of fixed dollar cost sharing inherent in the
benefit plans. That is, if no change in benefit mix is anticipated relative to the
Experience Period, the paid to allowed ratio should be higher in the projection period
than what was realized in the experience period due to the leveraging of cost sharing.
Projected Incurred Claims, before ACA rein & Risk Adj’t, PMPM: The template calculates this
value by multiplying the Projected Allowed Experience Claims PMPM (w/ applied credibility if
applicable) by the Paid to Allowed Average Factor in the Projection Period.
Projected Risk Adjustments, PMPM: Enter the projected PMPM amount of net federal risk
adjustment transfers (i.e., net effect of risk adjustment payments and charges) for the
Projection Period, and net of risk adjustment user fees.
The risk transfers should reflect the projected morbidity, including any projected
Population risk Morbidity changes in column J in Section II.
If the issuer expects to receive a projected risk adjustment charge, then the entry should
be a positive value. If the issuer expects to make a projected risk adjustment payment,
then the entry should be a negative value.
Risk adjustment user fees should be reflected here, and not in the Taxes & Fees.
The calculation of the projected risk adjustments should consider the appropriate
published transfer equation. Please describe the methodology for estimating the PMPM
amount in the Part III Actuarial Memorandum.
Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM: The
template calculates this value by subtracting the Projected Risk Adjustments, PMPM from the
Projected Incurred Claims, before ACA rein & Risk Adj’t, PMPM.
Projected ACA Reinsurance Recoveries, Net of Premium: Enter projected reinsurance
recoveries, referred to as reinsurance payments in the HHS Notice of Benefit and Payment
Parameters, from the Federal reinsurance program, less contributions made to the program
(referred to as “Premium” in the template).
Recoveries should be entered as positive amounts. For example, in the individual market
where recoveries will likely exceed assessments the amount should be positive. In
combined markets, the value may be positive or negative depending upon the portion of
the market that is expected to be comprised of individuals and small groups. In a
19
combined market, the pooled reinsurance adjustment should be based only on the
portion of the issuer’s individual market business eligible for reinsurance payments. For
the small group market, this amount only reflects the reinsurance assessment and
should be entered as a negative number.
Projected Incurred Claims: The template calculates this value by subtracting Projected Risk
Adjustments, PMPM and Projected ACA Reinsurance Recoveries, Net of Premium from
Projected Incurred Claims, before ACA rein & Risk Adj’t, PMPM.
Administrative Expense Load: Enter the administrative expense load included in the premiums
being filed for the effective date.
Enter the load as a percentage of premium. The template uses the percentage to
calculate the PMPM administrative expense load.
If the Administrative Expense Load varies by product or plan, enter the average expense
load for the single risk pool, using a premium‐weighted average.
The Administrative Expense Load should include expense loads related to quality
improvement and fraud detection/recovery, even if those expenses are considered part
of incurred claims for purposes of MLR rebate calculations. It should also include loads
for taxes and fees that may not be subtracted from premium in the MLR rebate
calculation. For reporting purposes, it should not include the profit and risk load or the
taxes and profit load, both described below, even though they are considered
administrative expenses for purposes of adjusting the Index Rate to arrive at premium in
the pricing process.
Profit & Risk Load: Enter the profit and risk load included in the premiums being filed for the
effective date.
Enter the load as a percentage of premium. Not‐for‐profit issuers should enter the load
for contribution to surplus in this entry. The template uses the percentage to calculate
the PMPM profit and risk load.
If the Profit & Risk Load varies by product or plan, enter the average profit and risk load
for the single risk pool, using a premium‐weighted average.
Since taxes (including any federal income tax) are captured separately in the Taxes &
Fees input, the profit and risk load should reflect after‐tax amounts.
Note that for pricing purposes, profit and risk load is considered part of administrative
expenses, per 45 CFR Part 156, §156.80(d). It is shown separately on the template to
facilitate rate review.
20
Taxes & Fees: Enter the taxes and fees included in the premiums being filed for the effective
date.
Enter only the portion of any load that is for taxes and fees that may be subtracted from
premiums for purposes of calculating MLR. This includes federal income tax. However,
do not include any contributions to the Federal transitional reinsurance program or risk
adjustment user fees in this amount despite their treatment in MLR calculations, since
Federal reinsurance and risk adjustment amounts are expressed in the template net of
reinsurance premium and risk adjustment user fees. Any additional load for taxes and
fees should be reflected in the Administrative Expense Load. The template uses the
percentage to calculate the PMPM Taxes & Fees.
If the Taxes & Fees percentage varies by product or plan, enter the average Taxes &
Fees percentage for the single risk pool, using a premium‐weighted average.
Note that for pricing purposes, taxes and fees are considered part of administrative
expenses, per 45 CFR Part 156, §156.80(d). It is shown separately on the template to
facilitate rate review.
Single Risk Pool Gross Premium Avg. Rate, PMPM: The template calculates this value by
dividing the Projected Incurred Claims by 1 minus the Administrative Expense Load percentage
less the Profit & Risk Load percentage less Taxes & Fees percentage.
Index Rate for Projection Period: Enter the projected Index Rate.
As noted in Section I, the Index Rate represents the average allowed claims PMPM for
essential health benefits. This legal entity‐specific rate for the projection period should
not reflect any adjustments for payments and charges under the risk adjustment and
reinsurance programs or for Exchange user fees. It is simply projected allowed claims
PMPM for essential health benefits. If the submission is for the individual or combined
market, the projected Index Rate should reflect the twelve month projection period, or
rating period. For the individual or combined market, if the issuer will not be covering
benefits in excess of EHB, the Index Rate for the projection period will be equal to the
Projected Allowed Experience Claims PMPM (w/ applied credibility if applicable). If the
submission is for the small group market and includes prospective trend adjustments
(only if permitted by the state), then the Index Rate for Projection Period should reflect
the member weighted average of the projected trended Index Rates applicable for each
effective date in the submission. See Section I for additional information about the
Index Rate. See the Appendix for further guidance on calculation of the small group
weighted average projected Index Rate.
% increase over Experience Period: The template calculates this value which represents the
percent increase in the projected average gross premium PMPM over the average gross
premium PMPM in the experience period. The average gross premium PMPM for the
21
experience period is calculated by the template in Section I (Premiums (net of MLR Rebate) in
Experience Period).
The calculated increase is not the proposed rate increase. The calculated increase may
include changes in premium PMPM related to shifts in the covered benefit, age,
geographic area, or tobacco status of the population, some of which may be charged to
the consumer through allowable rating factors.
The period of time over which the increase is calculated is dependent upon the
Experience Period entered by the issuer. For example, if the length of time between the
Experience Period and the Projection Period is two years, the increase calculated will
represent a two‐year increase.
% increase, annualized: The template calculates this value by annualizing the % increase over
Experience Period. Like the % increase over Experience Period, the calculated increase may
include changes in premium PMPM related to shifts in the covered benefits, age, geographic
area, or tobacco status of the population, some of which may be charged to the consumer
through allowable rating factors.
Projected Member Months: Enter the number of member months expected to be covered
during the Projection Period.
See ‘Experience Period Member Months’ in Section I for more information on how to
calculate member months. Since the Projection Period must be a one‐year period, the
projected member months might be equal to 12 times the projected enrollment in the
first month of the Projection Period, for example. Issuers should describe how the
member months were projected in the Part III Actuarial Memorandum.
Include all covered members even if premium is not expected to be explicitly collected
for all members, for example if the number of child members in a given family exceeds
three and must be capped for premium setting purposes as required by law.
Projected Period Totals: The template calculates aggregate dollar amounts for Section III
PMPM values entered into or calculated by the template. The amounts are calculated by
multiplying the Projected Member Months by the applicable PMPM value.
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Worksheet 2 – Plan Product Information
The purpose of Worksheet 2 is to capture information at the product and plan level. The
worksheet captures information on experience period data, the projection period data and
other information related to each product or plan. There are four sections in this worksheet.
• Section I captures information about each product and plan. This includes general
information such as the plan and product IDs, along with more specific information such
as the effective date, actuarial values and proposed rate increase.
• Section II displays the proposed rate increase by major service category and the
expected increase in cost sharing on a per member per month basis for each product
and plan.
• Section III captures historical information such as premium and claims in a more
detailed manner than in Worksheet 1. Information regarding the portion of the
premium and claims related to the EHBs and non‐EHBs is required, as well as
information related to risk transfer charges and payments, Federal reinsurance
payments, and cost sharing reduction amounts.
• Section IV contains the same information collected in Section III, but for the twelve
month period following the effective date shown in the rate filing for each product.
If a product contains both grandfathered and non‐grandfathered insurance policies, the
experience of grandfathered policies may be included on Worksheet 2 if the grandfathered
policies share the same rating practices as non‐grandfathered policies, including pooling of risks
and common rate increases or as permitted by the governing state regulatory body. If
experience of grandfathered policies is included, then the total experience on Worksheet 2 will
exceed that shown on Worksheet 1 which includes only non‐grandfathered experience.
Plan level data is required because it could be used in calculating the advance premium tax
credits and cost sharing subsidy advance payments. If the plan level data is not provided for
each plan, the calculation of the advance premium tax credit and cost sharing subsidy advance
payments may be incorrect for an issuer which may result in significant over or under advance
payments.
In all cases, reasonable projected values are to be entered for all plans, either directly or by
using the plan averaging option. For example, if an issuer chooses to enter information
separately for each plan, all information input into the Part I Unified Rate Review Template for
each plan must reflect experience or best estimate projections for each specific plan. For
example, projected member months must reflect the issuer’s best estimate of expected
enrollment in each plan. With the exception of terminated plans, no plan should have expected
membership of zero, and all membership projections should be supportable and represent the
actuary’s best estimate of enrollment. If zeros are entered in the Part I Unified Rate Review
23
Template, an issuer may be required to resubmit the template which may cause delays in the
rate review and approval process.
Section I
Product: Enter the product name in the corresponding column(s).
The term “product” is defined as a unique combination of benefits, various cost sharing
options and a network design(s) to a particular service area. “Product” has the same
meaning as included in 45 CFR Part 154.
All products included in the single risk pool experience shown on Worksheet 1 must be
entered in this section of Worksheet 2. This includes any products that are terminated
but have experience included in the single risk pool during the experience period. It also
includes any products that were not in effect during the experience but were made
available thereafter.
If multiple products will be closed prior to January 1, 2015, these products may be
combined for reporting purposes and shown as a single product in the template. The
term “Terminated Products” should be entered as the plan name in this case. The list of
product names for the terminated products should be included in the Part III Actuarial
Memorandum.
Currently, HIOS does not report product names containing special characters, e.g., %. It
is recommended that products containing special characters spell out the name of the
special character, e.g. “20Percent Coinsurance” for “20% Coinsurance.”
Product ID: Enter the product ID that corresponds with each product. The two‐letter state
code portion of the Product ID must be entered using capital letters.
The “Product ID” should be the product number assigned by HIOS. Each product
included in the single risk pool during the Experience Period, as well as new products
that are part of the rate filing, must be identified in Worksheet 2 of the template.
If multiple products will be closed prior to January 1, 2015, these products may be
combined for reporting purposes and shown as a single product in the template. Enter
the Product ID for the largest product (measured by member months during the
experience period) being terminated. A list of Product IDs for the terminated products
should be included in the Part III Actuarial Memorandum.
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Metal: For each “plan” within a product, choose the corresponding metal level from the drop
down menu in the template. Plans that are included in a QHP certification application must
show the same Metal as is shown in the QHP application.
In these instructions, the term “actuarial value” is used to describe a manner of
estimating the value of a plan, but not a specific manner. AV Metal Value refers to the
federal definition of actuarial value as prescribed in 45 CFR Part 156, §156.20. AV Pricing
Value is defined below.
The ACA requires that all plans offered in the market must have an actuarial value that
corresponds to a defined metal level. For guidance on the definition of “plan” please
see the definition of “Plan Name” in these instructions. The metal actuarial values are
defined as “the percentage paid by a health plan of the percentage of the total allowed
costs of benefits.”1 There are five levels of coverage that can be offered: Platinum, Gold,
Silver, Bronze and Catastrophic. The actuarial values for each of these metal levels are
shown in the table below. The actuarial value used in determining the metal level must
be based on the Actuarial Value Calculator (AV Calculator) or an acceptable alternative if
a health plan’s design is not compatible with the AV Calculator. For further guidance on
the calculation of the AV Metal Value in the determination of the metal level, please see
the instructions for the Part III Actuarial Memorandum.
The actuarial value used to determine the metal level must be within a de minimis
variation from the actuarial values defined in the ACA. The Secretary has provided
guidance that the de minimis variation standards will be ± 2 percentage points. For
example, plans with an AV value between 68% and 72% meet the requirements for a
silver level plan.
Metal Level
AV Requirements
Platinum
Gold
Silver
Bronze
Catastrophic
90%
80%
70%
60%
Not specified by law*
*Catastrophic level – a plan offered in the individual market only and is only available to individuals below the
age of 30 or those for whom premium for minimum essential coverage exceeds 8% of income.
For products that are reported on a combined basis as terminated products prior to
January 1, 2015, enter “Catastrophic”.
1 45 CFR Part 156, §156.20
25
AV Metal Value: For each plan, enter the corresponding AV value that results from the AV
Calculator or a permissible alternative method that complies with 45 CFR Part 156 §156.135(b).
For products that are reported on a combined basis as terminated products prior to
January 1, 2015, enter zero.
For Catastrophic plans, enter an approximate AV Metal Value for the plan (e.g., 0.580).
Since there is not a Catastrophic continuance table within the AV Calculator, the actuary
should use their best judgment in estimating the AV Metal Value.
AV Pricing Value: For each plan enter the corresponding AV Pricing Value.
It is important to note that the AV Pricing Value may be different from the AV Metal
Value for several reasons. The AV Pricing Value represents the cumulative effect of
adjustments made by the issuer to move from the Market Adjusted Index Rate to the
Plan Adjusted Index Rate. It is likely to have a spread from one plan to another that
emulates the spread in the Plan Adjusted Index Rates of the same plans.
The AV Metal Value compares the amount paid by a health plan to total allowed costs of
benefits for the given plan (e.g. the estimated paid costs for a gold plan is compared to
estimated allowed costs for a gold plan to generate a ratio between 0.78 and 0.82).
Another difference between the AV Pricing Value and the AV Metal Value is the data
used to generate the ratios. The AV Pricing Value is determined from the Issuer’s own
experience rather than the experience of the standard population or standard tables
that are used in the calculation of the AV Metal Value. In addition the AV Pricing Value
should reflect all of the allowable plan level adjustments to the Index Rate that are used
by the issuer. This may include some or all of the following adjustments, so long as the
adjustments do not include any assumptions related to the morbidity of the members
assumed to select a given plan:
• The cost‐sharing design of the plan. This adjustment may include expected
differences in utilization of services based on differences in cost sharing. For
example, lower cost sharing is generally associated with higher utilization of
services, independent of health status. This adjustment must not include any
differences in utilization due to differing health status of people with different
cost‐sharing designs.
• The plan’s provider network and delivery system characteristics, as well as
utilization management practices.
• Plan benefits in addition to the essential health benefits. The additional
benefits must be pooled with similar benefits provided in other plans to
determine the allowable rate variation for plans that offer those benefits.
26
• Administrative costs, excluding Exchange user fees.
• For catastrophic plans, the expected impact of specific eligibility categories for
these plans.
Plan Type: Select the applicable plan type from the drop‐down box. Valid Plan Types are
Indemnity, PPO, POS, HMO or EPO.
In the event that the list of plan types does not describe an issuer’s plan exactly, the
issuer should select the closest plan available and provide further explanation of the
Plan Type in the Part III Actuarial Memorandum.
Definitions of each of these categories can be found on the Healthcare.gov website in
the glossary. However, each state may have its own definition of these terms which
would dictate the plan type.
Plan Name: Enter the name of each plan within a product.
The term “plan” is defined as a unique combination of benefits to a specific set of cost
sharing options and network design(s) to a particular service area. Most products will
be made up of multiple plans that produce an actuarial value equal to one of the metal
levels permitted under the ACA. The Plan Name is the marketing name used when
referring to the specific set of benefits and cost sharing values. The Plan Name shown
should be consistent across submissions (e.g., QHP application, state filings).
All plans included in the single risk pool experience shown on Worksheet 1 must be
entered in this section of Worksheet 2. This includes any plans that are terminated but
have experience included in the single risk pool during the Experience Period. It also
includes any plans that were not in effect during the Experience Period but were made
available thereafter. Issuers should not enter cost sharing reduction plan variations
separately, since as described in 45 CFR 156.400‐156.420, plan variations are not
separate plans, but rather variations of the corresponding standard plans, with the same
premium, benefits, and network as the standard plan. Further instructions are provided
in Sections III and IV, below, on how to account for cost sharing reductions in this
template.
For products that are closed to new entrants prior to January 1, 2015, the issuer should
indicate that there is one plan in the product when completing the template. The Plan
Name for the product or grouping of terminated products should be entered as
“Terminated Products.”
Currently, HIOS does not report plan names containing special characters, e.g., %. It is
recommended that plans containing special characters spell out the name of the special
character, e.g. “20Percent Coinsurance Plan” for “20% Coinsurance Plan.”
27
Plan ID: Enter each assigned Plan ID. The two‐letter state code portion of the Plan ID must be
entered using capital letters.
The Plan ID is a unique identifier for the set of benefits and cost sharing values offered
within a product by the HIOS issuer, or in other words, a unique identifier of each plan.
Plan IDs contain three digits. This field must be entered as a text input and must include
any leading zeros (e.g. 001).
For products that are closed to new entrants prior to January 1, 2015, the issuer should
indicate that there is one plan in the product when completing the template. The Plan
ID for the product or grouping of terminated products should be populated with the
Product ID discussed above.
Exchange Plan: For each plan, enter an indicator (yes or no) as to whether the plan will be
offered inside a State‐based or Federally Facilitated Exchange or Small Business Health Options
Program (SHOP), regardless of whether or not it will also be offered in the outside market. If an
application for qualified health plan status is pending, enter “yes.” This indicator should not be
used to identify whether a plan is offered on a private exchange.
Historical Rate Increases: For each product, enter the historical rate increase for the period two
years prior to the current calendar year, one year prior to the current calendar year, and the
current calendar year.
For example, if the template is submitted in 2013 for an Effective Date of January 1,
2014, the current calendar year is 2013. Rate increases are therefore required to be
entered for 2011, 2012, and 2013.
Rate increases must reflect the full rate increase that is applied to a policy during the
applicable year. For example, if rate tables in the market change quarterly but each
policyholder’s premium rates change annually, then the rate increase for policies
renewing during the year must reflect the total rate change that applies to each
policyholder during that year, which is the cumulative effect of the four quarterly rate
changes.
If multiple rate increases were implemented during the calendar year period being
reported, enter the premium weighted average rate increase across the entire calendar
year. For example, assume the submission is for the small group market in which 50% of
groups (representing 50% of the annual revenue) renew in January, 25% renew in April,
and 25% renew in October. The calendar year increases are 7% in January, 6% in April,
and 5% in October, then the calendar year average rate increase is 6.25% (=7%*50% +
6%*25% + 5%*25%).
For the current calendar year, include all rate changes that have been approved, are
currently under review by the applicable regulatory agency, or are anticipated to be
28
submitted. For example, if the template is being submitted in April 2013 for an effective
date of January 1, 2014 for a market in which rates change quarterly, include in the
average rate increase for 2013 any rate increases that have already been approved or
are intended to be implemented in 2013 including those implemented after the
submission (e.g., effective July 2013 and October 2013).
For new plans, enter a value of ‐999% in the Historical Rate Increases. If a plan was
recently offered for the first time, and therefore does not have experience in the
Experience Period, enter the actual Historical Rate Increases in the same manner as
other existing plans. If an existing plan has not previously had a rate increase, enter
0.00%.
For terminated products, the historical rate increase fields are optional. However, since
the template expects an entry, enter ‐999% to avoid validation warnings.
Effective Date of Proposed Rates: For each plan, enter the corresponding effective date of the
proposed rate increases.
See Worksheet 1 instructions for Effective Date. All products and plans must have the
same effective date. If some products or plans will have a rate change and others will
not, then a 0% rate change may be entered in the “Rate Change % (over prior filing)”
field described immediately below for those plans that will not have a rate change on
the product’s effective date.
As on Worksheet 1, if the submission is for the small group market, enter the effective
date on which the products’ rates will change due to the Index Rate being revised. For
example, if the small group submission revises the Index Rate for July 1, 2015 effective
dates and includes a trend increase applicable on October 1, 2015, enter July 1, 2015.
Rate Change % (over prior filing): Enter the average change in premium rates over the rates
included in the prior filing for each plan.
For new plans enter 0.00% in this field.
Cum’tive Rate Change % (over 12 mos prior): Enter the average change in premium rates over
the twelve month period prior to the effective date for each plan. This should be the premium‐
weighted average of the 12‐month increases that apply at renewal.
For new plans enter ‐999.00% in this field. It is important to enter this value in the
template in this case so other calculated fields in the template are correctly generated.
Proj’d Per Rate Change % (over Exper. Period): For each plan, the percentage change in rates
between the Experience Period and the Projection Period is shown. This is a calculated field.
29
Product Threshold Rate Increase %: The template calculates the threshold rate increase for
each product. This is the rate increase that determines whether the rate increase is subject to
review, per 45 CFR Part 154 §154.200.
Section II: Components of Premium Increase (PMPM Dollar Amount
above Current Average Rate PMPM)
This section can be completed with variations only at the product level or variations at each
plan level within a product.
If the information is entered with the product level variation, this means the issuer
enters the information for the total product spread evenly across all plans within the
product. If the issuer chooses this methodology, the proposed rate increase for each
plan within the product must be identical.
If the issuer chooses to enter the information separately for each plan within a product
rather than use the simplified approach of entering the product averages, the proposed
rate increase for each plan can vary for items allowable by state and Federal laws and
regulations. If an issuer chooses to enter information separately for each plan, all
information input into the Part I Unified Rate Review Template for each plan must
reflect experience or best estimate projections for each specific plan. For example,
projected member months must reflect the issuer’s best estimate of expected
enrollment in each plan. With the exception of terminated plans, no plan should have
expected membership of zero. If zeros are entered in the Part I Unified Rate Review
Template, an issuer may be required to resubmit the template which may cause delays
in the rate review and approval process.
Inpatient: Enter the portion of the increase in the premium rate that corresponds to benefits
provided for inpatient services for each plan. See the instructions for Worksheet 1, Section II for
the definition of Inpatient Hospital services.
Outpatient: Enter the portion of the increase in the premium rate that corresponds to benefits
provided for outpatient services for each plan. See the instructions for Worksheet 1, Section II
for the definition of Outpatient Hospital services.
Professional: Enter the portion of the increase in the premium rate that corresponds to
benefits provided for professional services for each plan. See the instructions for Worksheet 1,
Section II for the definition of Professional services.
Prescription Drugs: Enter the portion of the increase in the premium rate that corresponds to
benefits provided for prescription drugs for each plan. See the instructions for Worksheet 1,
Section II for the definition of Prescription Drug services.
30
Other: Enter the portion of the increase in the premium rate that corresponds to benefits
provided for services defined in the “other” benefit category for each plan. See the instructions
for Worksheet 1, Section II for the definition of Other Medical services.
Capitation: Enter the portion of the increase in the premium rate that corresponds to benefits
provided for services defined under capitation for each plan. See the instructions for Worksheet
1, Section II for the definition of Capitation.
Administrative Expenses: Enter the portion of the increase in the premium rate that
corresponds to administrative expenses incorporated in the premium rates for each plan. See
the instructions for Worksheet 1, Section III for the definition of Administrative Expense Load.
Taxes & Fees: Enter the portion of the increase in the premium rate that corresponds to the
taxes and fees incorporated in the premium rates for each plan. Also include expected changes
in the payments and charges under the risk adjustment and reinsurance programs, in addition
to the administrative costs associated with these programs. Since the total rate increase is
affected by changes in anticipated transfer payments, these need to be reflected in order for
the total to be calculated correctly.
Risk & Profit Charges: Enter the portion of the increase in the premium rate that corresponds
to the risk and profit charges incorporated in the premium rates for each plan. See the
instructions for Worksheet 1, Section III for the definition of Profit & Risk Load.
Total Rate Increase: This is a calculated field and equals the sum of the benefit categories,
administrative expenses and the risk and profit charges for each plan. It should equal the
difference between the projected Average Rate PMPM and the Average Current Rate PMPM.
Member Cost Share Increase: Enter the expected increase in the member’s cost sharing
portion from the period underlying the current rate for the plan to the projected rating period
of the plan. This includes cost sharing paid by HHS on behalf of low‐income members.
This might reflect the impact of trend on coinsurance, for example. This would not
include any increase in the member’s cost associated with the increase in premium
rates.
Average Current Rate PMPM: Enter the average premium rate on a per member basis for each
plan for the most recently approved rates.
The Average Current Rate PMPM should be generated using the projected membership,
not the currently enrolled membership.
In the case of small group rates where a trend factor is filed and approved, the Average
Current Rate PMPM should reflect the latest approved rate. For example, assume the
current rates were filed for effective dates between January and December with a
31
quarterly trend factor. The current rates that should be entered in the rate filing would
be the rates with effective dates October through December.
For new plans (i.e., those with Cum’tive Rate Change % (over 12 mos prior) entered as ‐
999.00% as instructed above), enter the projected average rate PMPM for each plan in
this field. It is understood that these new plans do not actually have current rates.
However, it is necessary to populate this field with the projected average rate so that
the projected Average Rate PMPM in Section IV is calculated correctly by the template.
It is also understood that the calculated Average Current Rate PMPM across all plans will
not reflect the true current average in the event that there are new plans or very recently
offered plans with Projected Member Months (which are used to calculated the overall
average) but whose current rate reflects a rate for a later effective date than the
remaining plans that are not new. In fact, any time the Projected Member Months have
a different distribution across plans than the current distribution, the Average Current
Rate PMPM will not represent the true current average rate.
Projected Member Months: Enter the projected member months by plan that correspond to
the effective period of the rates for each plan. See the instructions for Worksheet 1, Section II
for the definition of Projected Member Months. The sum of the Projected Member Months for
each of the plans should equal the Projected Member Months on Worksheet 1.
The total Member Months in the projection period should be consistent with the
Projected Member Months entered in Section III of Worksheet 1. However, the member
months may differ if there are different effective dates for the products/plans. The
template includes a “Warning” indicator if there is a significant difference between the
member months found in Worksheet 1 and in Worksheet 2. In these cases, support for
the member months in both worksheets should be documented in the Part III Actuarial
Memorandum.
If an issuer chooses to enter information at the plan specific level, projected member
months entered in the template must reflect an issuer’s best estimate of projected
enrollment for that specific plan. With the exception of terminated plans, the projected
member months for a plan should not be zero. If the projected membership does not
meet this criteria, issuers may be required to resubmit the Part I Unified Rate Review
Template which may cause delays in the rate review and approval process.
Section III: Experience Period Information
The information shown in this section captures the historical data for the twelve month period
used in the base period experience. This should be the same time period as the Experience
Period found in Worksheet 1. See the instructions for Worksheet 1 for the definition of the
Experience Period.
32
Similar to Section II of this worksheet, the information requested in this section can be entered
at the product level or at the plan level. See Section II for a description of these variations.
Average Rate PMPM: Enter the average premium rate PMPM for each plan during the
experience period. The average should be generated using membership consistent with the
Experience Period for each plan.
It is anticipated that the overall Average Rate PMPM during the Experience Period
should be similar to the average premium rate found in Section I of Worksheet 1. The
template includes a “Warning” indicator if there is a significant difference between the
average premiums on the two worksheets. If the Warning is indicated, additional
information should be provided in the Part III Actuarial Memorandum that explains the
differential.
Member Months: Enter the total member months during the Experience Period. See the
instructions for Worksheet 1 for the definition of Experience Period Member Months.
The total Member Months in the Experience Period should be consistent with the
Experience Period Member Months entered in Worksheet 1. The template includes a
“Warning” indicator if there is a significant difference between the member months
found in Worksheet 1 and in Worksheet 2. In these cases, support for the member
months in both worksheets should be documented in the Part III Actuarial
Memorandum.
Total Premium (TP): The total premium earned in the Experience Period for each plan is
calculated as the Average Rate PMPM multiplied by the Member Months in a given plan.
The Total Premium (TP) in the experience period should be consistent with the total
premium found in Section I of Worksheet 1. The template includes a “Warning”
indicator if there is a significant difference between the total premiums shown on both
worksheets. If the Warning is indicated, additional information should be provided in
the Part III Actuarial Memorandum that explains the cause.
EHB Percent of TP: Enter the percentage of the total premium that is associated with EHB
services in each plan (including administrative expenses and profit associated with those
services). Note these fields are optional for submissions with an experience period that ends
prior to January 1, 2014.
When calculating the EHB Percent of TP, the Administrative Expense Load, Profit & Risk
Load, and Taxes & Fees should be allocated to the various categories in this section
(EHB, state mandated benefits that are not EHB, and other benefits) of the template in
proportion to the claims expenses. For example, if 95% of claims are EHB and 5% of
claims are other benefits, then the EHB Percent of TP should be 95%. Similarly, the
Other benefits portion of TP should be 5% in the example and would be calculated as
33
such by the template. Administrative expenses and profit should not be
disproportionately allocated to one benefit over another. The sum of the EHB
percentage, the state mandated benefits percentage and the other benefits percentage
should equal 100%.
If abortion services are included in the EHB package, the portion of the premium related
to these services is to be handled using two different methods in accordance with the
criteria described below.
• If the plan is a QHP offered in the Federally Facilitated Exchange or State‐Based
Exchange, the percentage of the premium associated with abortion services
should not be included in the EHB percentage (even though these services may
be in the EHB benchmark package). The EHB percentage will be used in the
calculation of subsidy amounts. Since subsidy payments may not be provided for
costs associated with abortion services, they must be excluded from the EHB
proportion.
• If the plan is not a QHP offered in the Federally Facilitated Exchange or State‐
Based Exchange, but rather is only offered in the outside market, the percentage
of premium associated with abortion services should be included in the EHB
percentage.
If abortion services are not included in the EHB benchmark package, any covered
abortion services should be reflected in either the state mandated benefits portion or
the other benefits portion regardless of whether the plan is sold inside or outside of the
exchange.
State mandated benefits portion of TP that are other than EHB: Enter the percentage of the
total premium for each plan that is associated with state mandated benefits that are not part of
the EHB package. Note these fields are optional for submissions with an experience period that
ends prior to January 1, 2014.
Similar to the EHB percentage, the state mandated benefit percentage of the total
premium should include the portion of administrative expenses, taxes and fees and risk
and profit loads associated with these services.
State mandated benefits that are not part of the EHB package that are required to be
offered only (i.e. it is the choice of the insured as to whether or not to purchase the
benefits) should not be included in this component as the benefit is optional from the
purchaser’s perspective. The premium associated with these types of benefits should be
included in the Other benefits portion of the premium, which is defined below.
34
The percentages in these fields are required (except for the optional treatment
described above) as states will need to fund the portion of the premium for state
mandated benefits that are not included in the EHB package.
Other benefits portion of TP: This is a calculated field which generates the remaining
percentage of the total premium based on the values entered from the EHB and state
mandated benefits portions, described above.
As stated previously, the sum of the EHB portion, the state mandated benefit portion
not associated with EHBs and the other benefits portion should equal 100%.
Total Allowed Claims (TAC): Enter the total allowed claims for each benefit plan with service
dates within the Experience Period.
The Total Allowed Claims (TAC) across all benefit plans for the Experience Period should
be consistent with the Allowed Claims entered in Section I of Worksheet 1. The template
includes a “Warning” indicator when the allowed claims between Worksheet 1 and
Worksheet 2 are significantly different. If a Warning is indicated, the issuer should
provide additional support for the difference between the total allowed claims between
Worksheet 1 and 2 in the Part III Actuarial Memorandum.
EHB Percent of TAC: Enter the percentage of the total allowed claims that are associated with
EHB services in each plan during the Experience Period. Note these fields are optional for
submissions with an Effective Date, as shown on Worksheet 1, in calendar year 2015.
If abortion services are included in the EHB package, the portion of the allowed claims
related to these services is to be handled in two different methods in accordance with
the criteria described below.
• If the plan is a QHP offered in the Federally Facilitated Exchange or State‐Based
Exchange, the percentage of the allowed claims associated with abortion
services should not be included in the EHB percentage (even though these
services may be in the EHB package).
• If the plan is not a QHP offered in the Federally Facilitated Exchange or State‐
Based Exchange, but rather is only offered in the outside market, the percentage
of allowed claims associated with abortion services should be included in the
EHB percentage.
If abortion services are not included in the EHB package, any covered abortion services
should be reflected in either the state mandated benefits portion or the other benefits
portion regardless of whether the plan is sold inside or outside of the exchange.
35
State mandated benefits portion of TAC that are other than EHB: Enter the percentage of the
total allowed claims for each plan that are associated with state mandated benefits that are not
part of the EHB package. Note these fields are optional for submissions with an experience
period ending prior to January 1, 2014.
State mandated benefits that are not part of the EHB package that are required to be
offered only (i.e. it is the choice of the insured whether the benefits are purchased)
should not be included in this component as the benefit is optional from the purchaser’s
perspective. The allowed claims associated with these types of benefits should be
included in the Other benefits portion, which is defined below.
Other benefits portion of TAC: This is a calculated field which generates the remaining
percentage of the total allowed claims based on the values entered from the EHB and state
mandated benefits portions, described above.
As stated previously, the sum of the EHB portion, the state mandated benefit portion
not associated with EHBs and the other benefits portion should equal 100%.
Allowed Claims which are not the issuer’s obligation: Enter the portion of the allowed claims
(as defined on Worksheet 2) that were paid by the insured or other funds for each plan
separately during the experience period. These would include the following types of payments:
• Member cost sharing (i.e. deductible, coinsurance and copays). This should be based
on the cost sharing associated with the benefits of each plan. For those plans with
reduced cost sharing subsidies for the member, the cost sharing amount included
this value should reflect both the amount paid by the member and the subsidies. For
example, for the silver plan variation with 94% cost sharing, the value of the cost
sharing included in this field should reflect the approximately 6% cost sharing
expected from the member and the approximately 24% cost sharing covered by the
federal subsidy for a total cost sharing value of approximately 30% (6% + 24%).
• Risk transfer charges or payments associated with the risk adjustment program. In
this case, risk adjustment charges made to the program should be entered as a
negative amount and payments received from the program should be entered as a
positive amount. The issuer should estimate the risk transfer charge or payment by
plan and provide detailed information in the Part III Actuarial Memorandum on the
methodology used to allocate the payments between plans. The risk adjustment
user fees should not be included since they are not part of allowed claims.
• Federal reinsurance payments received should be included in this field. The federal
reinsurance payments should be entered by plan. Payments should be entered as
positive amounts. The method used to determine these payments by plan should be
described in the Part III Actuarial Memorandum. The federal reinsurance
contributions should not be included since they are not part of allowed claims.
36
• Other claims that are not described above but included in this cell should be
described in detail in the Part III Actuarial Memorandum.
Portion of above payable by HHS’s fund on behalf of insured person, in dollars: Enter the
portion of the total dollars that are attributable to HHS during the Experience Period. This is the
cost sharing reduction subsidies.
Portion of above payable by HHS on behalf of insured person, as %: This is a calculated field
and displays the percentage of claims covered by HHS over the value of all claims not covered
by the issuer.
Net Amt of Rein: Enter the Federal reinsurance amount received for each plan during the
Experience Period.
This value should be calculated consistently with the federal reinsurance amount
included in the Allowed Claims which are not the issuer’s obligations. However, it will
differ from that amount in that this field is net of the reinsurance contribution amount.
For time periods prior to 2014, the value should be zero, as the program was not
operational until 2014.
Net Amt of Risk Adj: Enter the risk transfer charge or payment during the Experience Period for
each plan.
This value should be calculated consistently with the risk transfer charge or payment
included in the Allowed Claims which are not the issuer’s obligation. However, it will
differ from that amount in that this field is net of the risk adjustment user fees. If the
transfer amount is a charge (liability payment made to other issuers) the value should
be a negative amount. If the transfer amount is a payment received from other issuers
the value should be entered as a positive amount.
For time periods prior to 2014, the value should be zero, as the program was not
operational until 2014.
Section IV : Projected (12 months following effective date)
The information shown in this section captures the projected data for the twelve month period
following the effective date for each plan. Similar to Sections II and III of this worksheet, the
information requested in this section can be entered at the product level or at the plan level.
See Section II for a description of these variations.
It is expected that in general, the projection period found in this section should be the same as
the Projection Period found in Section II of Worksheet 1. However, there are circumstances
37
where the projection periods may differ. These circumstances occur in the small group market
when prospective trend is included in the submission (if permitted by the state). In this case:
Similar to the Index Rate for Projection Period on Worksheet 1, the Plan Adjusted Index
Rate must reflect the member weighted average of the projected trended plan adjusted
Index Rates applicable for all effective dates in the submission. See the Appendix for
more information on the calculation of the member weighted average Index Rate.
Member months should be consistent with those reflected on Worksheet 1. Since the
single risk pool requires the Index Rate be based on ALL enrollees in the market in the
state for that issuer, the member months should reflect all projected member months
for the single risk pool in the projection period, regardless of the expected renewal
month.
Since Total Premium (TP) for the projection period is calculated as the Plan Adjusted
Index Rate multiplied by the member months, this will reflect the weighted average Plan
Adjusted Index Rates for all effective dates.
All data entered in the Claims Information section (rows 86 through 96) should be consistent
with the projection period shown on Worksheet 1. Therefore, the amount of trend reflected in
the claims section will differ from that reflected in the premium information.
Plan Adjusted Index Rate: Enter the projected Plan Adjusted Index Rate into these cells for
each plan ID for the effective period of the proposed rates.
The Plan Adjusted Index Rate is the Market Adjusted Index Rate (defined in the
introduction of these instructions) further adjusted for plan specific factors allowable by
45 CFR Part 156.80(d)(2) such as provider network, utilization management, benefits in
addition to Essential Health Benefits (EHBs), actuarial value and cost sharing,
distribution and administrative costs (less Exchange fees) and catastrophic plan
eligibility variation.
The overall weighted average of the Plan Adjusted Index Rates should be similar to the
Single Risk Pool Gross Premium Avg. Rate, PMPM found in Section III of Worksheet 1.
The template includes a “Warning” indicator if there is a significant difference between
the average premiums on the two worksheets. If the Warning is indicated, additional
information should be provided in the Part III Actuarial Memorandum that explains the
differential. One explanation that may apply is that the small group Plan Adjusted Index
Rates reflect the member weighted average of the rates for all effective dates in the
filing, whereas the Worksheet 1 Single Risk Pool Gross Premium Avg. Rate reflects the
effective date of the change in the Index Rate.
Member Months: The template populates the projected Member Months using the Projected
Member Months entered in Section II of the worksheet.
38
Total Premium (TP): The total premium earned in the projection period for each plan is
calculated as the Average Rate PMPM multiplied by the Member Months in a given plan.
The Total Premium (TP) in the projection period should be similar to the total premium
found in Section III of Worksheet 1. The template includes a “Warning” indicator if there
is a significant difference between the total premiums shown on both worksheets. If the
Warning is indicated, additional information should be provided in the Part III Actuarial
Memorandum that explains the cause.
EHB Percent of TP: Enter the percentage of the total premium that is associated with EHB
services in each plan. It is critical that this percentage be entered correctly, and consistently
with any QHP application. It is likely that this field will be used by CCIIO to calculate the advance
premium tax credits for subsidy‐eligible enrollees. If the values in this field are not entered
correctly, the calculation of the advance premium tax credits may be incorrect for an issuer.
For non‐terminated ACA compliant plans, the value entered into the EHB Percent of TP field
must be greater than zero. It is critical that this percentage be entered correctly as it is likely it
will be used to calculate the advance premium tax credits for subsidy‐eligible members.
For pre‐ACA plans and terminated plans, the field may be left blank.
When calculating the EHB percentage, the Administrative Expense Load, Profit & Risk
Load, and Taxes & Fees should be allocated to the various categories in this section of
the template in proportion to the claims expenses. The sum of the EHB percentage, the
state mandated benefits percentage and the other benefits percentage should equal
100%.
If abortion services are included in the EHB package, the portion of the premium related
to these services is to be handled using two different methods in accordance with the
criteria described below.
• If the plan is a QHP offered in the Federally Facilitated Exchange or State‐Based
Exchange, the percentage of the premium associated with abortion services
should not be included in the EHB percentage (even though these services may
be in the EHB benchmark package). The EHB percentage will be used in the
calculation of subsidy amounts. Since subsidy payments may not be provided for
costs associated with abortion services, they must be excluded from the EHB
proportion.
• If the plan is not a QHP offered in the Federally Facilitated Exchange or State‐
Based Exchange, but rather is only offered in the outside market, the percentage
of premium associated with abortion services should be included in the EHB
percentage.
39
If abortion services are not included in the EHB benchmark package, any covered
abortion services should be reflected in either the state mandated benefits portion or
the other benefits portion regardless of whether the plan is sold inside or outside of the
exchange.
Submission of the Part I Unified Rate Review Template and corresponding Part III
Actuarial Memorandum satisfies the requirements of 45 CFR 154.215 and 156.470.
State mandated benefits portion of TP that are other than EHB: Enter the percentage of the
total premium for each plan that is associated with state mandated benefits that are not part of
the EHB package.
Similar to the EHB percentage, the state mandated benefit percentage of the total
premium should include the portion of administrative expenses, taxes and fees and risk
and profit loads associated with these services.
State mandated benefits that are not part of the EHB package that are required to be
offered only (i.e. it is the choice of the insured whether the benefits are purchased)
should not be included in this component as the benefit is optional from the purchaser’s
perspective. The premium associated with these types of benefits should be included in
the Other benefits portion of the premium, which is defined below.
The percentages in these fields are required as states will need to fund the portion of
the premium for state mandated benefits that are not included in the EHB package.
Other benefits portion of TP: This is a calculated field which generates the remaining
percentage of the total premium based on the values entered from the EHB and state
mandated benefits portions, described above.
As stated previously, the sum of the EHB portion, the state mandated benefit portion
not associated with EHBs and the other benefits portion should equal 100%.
Total Allowed Claims (TAC): Enter the total allowed claims for each benefit plan with service
dates within the projection period. See the instructions for Worksheet 1 for the definition of
Allowed Claims.
The Total Allowed Claims (TAC) across all benefit plans for the projection period should
be consistent with the total allowed claims, the projected risk adjustments and the
projected ACA reinsurance recoveries entered in Section III of Worksheet 1. The
template includes a “Warning” indicator when the sum of the allowed claims, the
projected risk adjustments and the projected ACA reinsurance recoveries in Worksheet
1 and the allowed claims in Worksheet 2 are significantly different. If a Warning is
indicated, the issuer should provide additional support for the difference between these
amounts in the Part III Actuarial Memorandum.
40
EHB Percent of TAC: Enter the percentage of the total allowed claims that are associated with
EHB services in each plan during the projection period. If abortion services are included in the
EHB package, the portion of the allowed claims related to these services is to be handled in two
different methods in accordance with the criteria described below. It is critical that this
percentage be entered correctly. This field is used by CCIIO to calculate cost sharing reduction
advance payments for subsidy‐eligible enrollees. If the values in this field are not entered
correctly, the calculation of the cost sharing reduction advance payments may be incorrect for
an issuer.
• If the plan is a QHP offered in the Federally Facilitated Exchange or State‐Based
Exchange, the percentage of the allowed claims associated with abortion
services should not be included in the EHB percentage (even though these
services may be in the EHB package).
• If the plan is not a QHP offered in the Federally Facilitated Exchange or State‐
Based Exchange, but rather is only offered in the outside market, the percentage
of allowed claims associated with abortion services should be included in the
EHB percentage.
If abortion services are not included in the EHB package, any covered abortion services
should be reflected in either the state mandated benefits portion or the other benefits
portion regardless of whether the plan is sold inside or outside of the exchange.
Submission of the Part I Unified Rate Review Template and corresponding Part III
Actuarial Memorandum satisfy the requirements of 45 CFR 154.215 and 156.470.
State mandated benefits portion of TAC that are other than EHB: Enter the percentage of the
total allowed claims for each plan that are associated with state mandated benefits that are not
part of the EHB package.
State mandated benefits that are not part of the EHB package that are required to be
offered only (i.e. it is the choice of the insured whether the benefits are purchased)
should not be included in this component as the benefit is optional from the purchaser’s
perspective. The allowed claims associated with these types of benefits should be
included in the Other benefits portion, which is defined below.
Other benefits portion of TAC: This is a calculated field which generates the remaining
percentage of the total allowed claims based on the values entered from the EHB and state
mandated benefits portions, described above.
As stated previously, the sum of the EHB portion, the state mandated benefit portion
not associated with EHBs and the other benefits portion should equal 100%.
41
Allowed Claims which are not the issuer’s obligation: Enter the portion of the allowed claims
(as defined in Worksheet 2) that were paid by the insured or other funds for each plan
separately during the projection period. These would include the following types of payments:
• Member cost sharing (i.e. deductible, coinsurance and copays). This should be based
on the cost sharing associated with the benefits of each plan. For those plans with
reduced cost sharing subsidies for the member, the cost sharing amount included
this value should reflect both the amount paid by the member and the subsidies.
• Risk transfer charges or payments associated with the risk adjustment program. In
this case, risk adjustment charges made to the program should be entered as a
negative amount and payments received from the program should be entered as a
positive amount. The issuer should estimate the risk transfer charge or payment by
plan and provide detailed information in the Part III Actuarial Memorandum on the
methodology used to allocate the payments between plans.
• Federal reinsurance payments expected to be received should be included in this
field. The federal reinsurance payments should be entered by plan. Payments should
be entered as positive amounts. The method used to determine these payments by
plan should be described in the Part III Actuarial Memorandum.
• Other claims that are not described above but included in this cell should be
described in detail in the Part III Actuarial Memorandum.
Portion of above payable by HHS’s fund on behalf of insured person, in dollars: Enter the
portion of the total dollars that are attributable to HHS during the projection period. This is the
cost sharing reduction subsidies.
These estimates should be based on the issuer’s expected enrollment of cost sharing
reduction eligible members. The methodology used to estimate these values should be
explained in the Part III Actuarial Memorandum.
Since this value is a portion of the payments entered in the Allowed Claims which are
not the issuer’s obligations (described above), the same methodology to estimate these
payments should be employed.
Portion of above payable by HHS on behalf of insured person, as %: This is a calculated field
and displays the percentage of claims covered by HHS over the value of claims not covered by
the issuer.
Net Amt of Rein: Enter the Federal reinsurance amount expected to be received for each plan
during the projection period, net of the reinsurance assessments.
42
This value should reflect both assessments charged and payments received under the
program. The amount entered should be consistent with the amount that reflects
payments received or assessments charged under the Federal reinsurance program that
is included in the Allowed Claims which are not the issuer’s obligations.
Net Amt of Risk Adj: Enter the amount of any risk transfer payment expected to be received
during the projection period for each plan. If a risk transfer charge is anticipated to be assessed,
the value entered should be negative.
This value should be consistent with the risk transfer payment, if any, included in the
Allowed Claims which are not the issuer’s obligation. If the transfer amount is expected
to be a payment received from other issuers the value should be entered as a positive
amount. If the transfer amount is expected to be a charge (liability payment made to
other issuers) a negative value should be entered.
Validation and Finalization of Part I Unified Rate Review Template
(URRT) in HIOS
An issuer must validate the URRT submission in order to complete the upload process within
HIOS. The following steps are to be taken in order to complete the process.
1. The issuer creates the initial submission and uploads the required documentation. At this
point the submission is in the Pre‐Validation status.
2. The issuer must check the validation box on the submission summary. Once the issuer
checks this box, the submission is in the Record Validated status.
43
Appendix
Single Risk Pool and Index Rate Requirements
The Single Risk Pool and Index Rate Requirements are specified in 45 CFR Part 156.80.
45 CFR Part 156.80(a), (b), and (c) require that health insurance issuers consider the claims
experience of all enrollees in all non‐grandfathered health plans subject to section 2701 of the
Public Health Services Act and offered by the issuer in the state to be members of a single risk
pool for each of the individual, small group, and combined markets.
45 CFR Part 156.80(d) requires that a health insurance issuer establish an Index Rate for each of
the individual, small group, or combined markets annually. The Index Rate for each market is
based on the total combined claims costs for providing Essential Health Benefits within the
Single Risk Pool for that state market.
Timeframe for Part 1 Unified Rate Review Template Submissions
The following table provides the guidelines for the submission of the Part 1 Unified Rate Review
Template for rates associated with the different types of public exchanges (i.e. FFM/SPM), and
non‐QHPs. This applies to filings for January 1 effective dates in all markets.
Type of Filing
Issuer Submission
Date for 2015 Rates
QHP Filing – FFM/SPM
[TBD]
QHP Filing – SBM
Based on state
regulatory agency
requirements
Non-QHP Filing
Based on state
regulatory agency
requirements
44
In addition, issuers may file revised rates for small group plans on a quarterly basis,
subject to other state requirements. For example, a state may not allow issuers to
submit revised rates for fourth quarter. The table below shows suggested guidance for
a timeline of submission of these plans. However, the specific submission dates may
vary from these guidelines depending upon specific requirements for individual states.
Small Group Quarterly Submission Schedule (Non‐Grandfathered Single Risk Pool Plans)
Type of Filing
Issuer Submission
Date
Finalization Date for
2015 Rates
QHP Filing – FFM/SPM
At least 90 days
prior to effective
date
At least 45 days prior
to effective date
QHP Filing – SBM
At least 90 days
prior to effective
date
At least 45 days prior
to effective date
Non-QHP Filing
Based on state
regulatory agency
requirements
At least 45 days prior
to effective date
Use of the Data Submitted in the URRT
CCIIO uses the data submitted in the URRT in a variety of ways.
In states where CCIIO performs the Market Reform Rules compliance reviews, CCIIO uses the
URRT in conjunction with other information to perform the compliance reviews.
CCIIO’s Financial Management may use certain fields in the calculation of Advance Premium Tax
Credit (APTC) payments and Cost Sharing Reduction (CSR) advance payments.
Disclosure of the URRT data
Upon completion of the Freedom of Information Act review that is underway, CCIIO will
disclose the data included in the URRT on its website.
URRT Submission Statuses
URRT submissions are in the following statuses under various circumstances.
The URRT contains no rate increases that are subject to review
45
Pre‐validation – the issuer has successfully created the URRT submission
Record Validated – this issuer has validated the URRT submission. Once the
issuer has validated the submission, the issuer must request authorization if they
need to revise the submission.
Pending Resubmission – the URRT submission has been “unlocked” to allow the
issuer to upload a revision to one or more of the documents. The URRT
submission needs to be re‐validated after the revised documents have been
uploaded.
Rate Filing Accepted – review of the URRT submission has been completed. If
any revisions are necessary after the submission is put into this status, the
submission will need to be deactivated and the issuer will need to create a new
URRT submission
The URRT contains one or more rate increases that are subject to review
Pre‐validation – the issuer has successfully created the URRT submission
Record Validated – this issuer has validated the URRT submission. Once the
issuer has validated the submission, the issuer must request authorization if they
need to revise the submission.
Pending Resubmission – the URRT submission has been “unlocked” to allow the
issuer to upload a revision to one or more of the documents. The URRT
submission needs to be re‐validated after the revised documents have been
uploaded.
Submission Filed – preliminary review of the submission has been completed by
the appropriate regulator.
Review in Progress – submission is pending final determination.
Review Complete – final determination has been entered by the appropriate
regulator.
46
How to Request a Revision to a URRT Submission
While a submission is in the “Pre Validation” status, the issuer may revise the submission at
will.
Once the issuer has validated the submission, the issuer must request authorization if they
need to revise the submission. To request authorization to revise the submission, send an
email to ratereview@cms.hhs.gov with the following information:
• Submission tracking number.
• Description of the specific changes you are requesting. Include any necessary
explanation of the revisions and the reasons the revisions are required.
• An indication that the appropriate regulator has authorized the requested revision.
• An indication of whether the submission contains any Exchange plans.
• An indication of whether the Index Rate will change as a result of the revisions to the
submission.
If the requested revision is authorized, the issuer needs to re‐validate the submission after the
revised documents have been uploaded.
Guidance for Quarterly Rate Increases
This appendix provides guidance on a methodology for the completion of the Part I Unified Rate
Review template in the small group market when an issuer chooses to file rates with predefined
quarterly trend increases. The guidance provided is not the required methodology, but rather
an example of how the template could be completed.
Premium rates for products in the small group market may be allowed to change on a quarterly
basis for trend, if not prohibited by the state. If an issuer chooses to increase rates on a
quarterly basis for trend, the issuer may file for trend increases for a specified period of time.
However, the Index Rate for the projection period must be reflective of each of the trended
rates effective during the period.
A methodology that could be used to calculate the Index Rate would be to develop a weighted
average using each effective premium rate and the expected number of members at the
corresponding premium level. This would be performed for each renewal month during the
twelve month period. For example, in the template filed for a January effective date, the Index
Rate would be calculated for each renewal month (January through December). The December
rates in this example would be weighted with the expected enrollment for December renewals
47
for the twelve‐month rating period from December of that year through November of the next
year. The table below shows an example of this calculation and the Index Rate that could be
entered into the Part I Unified Rate Review template.
The example is an issuer that wishes to change their small group rates on a quarterly basis using
an annual trend of 5%. The template is submitted for a January 1 effective date.
Effective Dates
January
April
July
October Total Single Risk Pool
Member Months
1000
500
1000
500
3000
Base Allowed Claims
$ 250.00
$ 250.00
$ 250.00
$ 250.00
$
250.00
Months of Trend
24
27
30
33
Annual Trend Rate
5%
5%
5%
5%
Single Risk Pool Projected
Allowed Claims
$ 275.63
$ 279.01
$ 282.43
$ 285.90
$
280.17
Index Rate Entered in
January Template
$ 280.17
Effective Date Entered in
January Template
1/1/xxxx
The quarterly trend factor for each quarter should be included in the Part III Actuarial
Memorandum, and support should be provided. Please see the instructions for the Part III
Actuarial Memorandum for further information.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Unified Rate Review v2.0.2
Company Legal Name:
State:
HIOS Issuer ID:
Market:
Effective Date of Rate Change(s):
Market Level Calculations (Same for all Plans)
Section I: Experience period data
Experience Period:
to
12/30/1900
Experience Period
Aggregate Amount
PMPM
% of Prem
Premiums (net of MLR Rebate) in Experience Period:
#DIV/0!
#DIV/0!
Incurred Claims in Experience Period
#DIV/0!
#DIV/0!
Allowed Claims:
#DIV/0!
#DIV/0!
Index Rate of Experience Period
Experience Period Member Months
Section II: Allowed Claims, PMPM basis
Experience Period
Projection Period:
1/0/1900
to
12/30/1900
Mid‐point to Mid‐point, Experience to Projection:
‐6 months
on Actual Experience Allowed
Adj't. from Experience to
Projection Period
Projections, before credibility Adjustment
Credibility Manual
Benefit Category
Utilization
Description
Utilization per
1,000
Average
Cost/Service
PMPM
Pop'l risk
Morbidity
Other
Cost
Util
Utilization per
1,000
Average
Cost/Service
PMPM
Utilization
per 1,000
Average
Cost/Service
PMPM
Inpatient Hospital
$0.00
#DIV/0!
#DIV/0!
#DIV/0!
$0.00
Outpatient Hospital
0.00
#DIV/0!
#DIV/0!
#DIV/0!
0.00
Professional
0.00
#DIV/0!
#DIV/0!
#DIV/0!
0.00
Other Medical
0.00
#DIV/0!
#DIV/0!
#DIV/0!
0.00
Capitation
0.00
#DIV/0!
#DIV/0!
#DIV/0!
0.00
Prescription Drug
0.00
#DIV/0!
#DIV/0!
#DIV/0!
0.00
Total
$0.00
#DIV/0!
$0.00
After Credibility
Projected Period Totals
Section III: Projected Experience:
Projected Allowed Experience Claims PMPM (w/applied credibility if applicable)
100.00%
#DIV/0!
#DIV/0!
Paid to Allowed Average Factor in Projection Period
Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM
#DIV/0!
#DIV/0!
Projected Risk Adjustments PMPM
0
Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM
#DIV/0!
#DIV/0!
Projected ACA reinsurance recoveries, net of rein prem, PMPM
0
Projected Incurred Claims
#DIV/0!
#DIV/0!
Administrative Expense Load
#DIV/0!
#DIV/0!
Profit & Risk Load
#DIV/0!
#DIV/0!
Taxes & Fees
#DIV/0!
#DIV/0!
Single Risk Pool Gross Premium Avg. Rate, PMPM
#DIV/0!
#DIV/0!
Index Rate for Projection Period
% increase over Experience Period
#DIV/0!
% Increase, annualized:
#DIV/0!
Projected Member Months
Information Not Releasable to the Public Unless Authorized by Law: This information has not been publically disclosed and may be privileged and confidential. It is for internal government use only and must not be
disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Annualized Trend
Factors
1 of 2
Product‐Plan Data Collection
Company Legal Name:
State:
HIOS Issuer ID:
Market:
Effective Date of Rate Change(s):
Product/Plan Level Calculations
Section I: General Product and Plan Information
Product
Product ID:
Metal:
AV Metal Value
AV Pricing Value
Plan Type:
Plan Name
Plan ID (Standard Component ID):
Exchange Plan?
Historical Rate Increase ‐ Calendar Year ‐ 2
Historical Rate Increase ‐ Calendar Year ‐ 1
Historical Rate Increase ‐ Calendar Year 0
Effective Date of Proposed Rates
Rate Change % (over prior filing)
Cum'tive Rate Change % (over 12 mos prior)
Proj'd Per Rate Change % (over Exper. Period)
Product Threshold Rate Increase %
Section II: Components of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM)
Plan ID (Standard Component ID):
Total
Inpatient
#REF!
Outpatient
#REF!
Professional
#REF!
Prescription Drug
#REF!
Other
#REF!
Capitation
#REF!
Administration
#REF!
Taxes & Fees
#REF!
Risk & Profit Charge
#REF!
Total Rate Increase
#REF!
Member Cost Share Increase
#REF!
Average Current Rate PMPM
#REF!
Projected Member Months
#REF!
ction III: Experience Period Information
Plan ID (Standard Component ID):
Total
Average Rate PMPM
#REF!
Member Months
#REF!
Total Premium (TP)
#REF!
EHB Percent of TP, [see instructions]
#REF!
state mandated benefits portion of TP that are other
than EHB
#REF!
Other benefits portion of TP
#REF!
Total Allowed Claims (TAC)
#REF!
EHB Percent of TAC, [see instructions]
#REF!
state mandated benefits portion of TAC that are
other than EHB
#REF!
Other benefits portion of TAC
#REF!
Allowed Claims which are not the issuer's obligation:
#REF!
Portion of above payable by HHS's funds on
behalf of insured person, in dollars
#REF!
Portion of above payable by HHS on behalf of
insured person, as %
#REF!
Total Incurred claims, payable with issuer funds
#REF!
Net Amt of Rein
#REF!
Net Amt of Risk Adj
#REF!
Incurred Claims PMPM
#REF!
Allowed Claims PMPM
#REF!
EHB portion of Allowed Claims, PMPM
#REF!
ction IV: Projected (12 months following effective date)
Plan ID (Standard Component ID):
Total
Plan Adjusted Index Rate
#REF!
Member Months
#REF!
Total Premium (TP)
#REF!
EHB Percent of TP, [see instructions]
#REF!
state mandated benefits portion of TP that are other
than EHB
#REF!
Other benefits portion of TP
#REF!
Total Allowed Claims (TAC)
#REF!
EHB Percent of TAC, [see instructions]
#REF!
state mandated benefits portion of TAC that are
other than EHB
#REF!
Other benefits portion of TAC
#REF!
Allowed Claims which are not the issuer's obligation
#REF!
Portion of above payable by HHS's funds on
behalf of insured person, in dollars
#REF!
Portion of above payable by HHS on behalf of
insured person, as %
#REF!
Total Incurred claims, payable with issuer funds
#REF!
Net Amt of Rein
#REF!
Net Amt of Risk Adj
#REF!
1
Attachment 3
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-15
Baltimore, Maryland 21244-1850
Part III Actuarial Memorandum and Certification
Instructions
February 3, 2014
2
Actuarial Memorandum and Certification
A Part III Actuarial Memorandum, including a corresponding actuarial certification, must be
submitted with each Part I Unified Rate Review Template. Please see the instructions for
completing the Part I Unified Rate Review Template for circumstances in which the template
must be completed and for which products.
All issuers are required to set the Index Rate for an effective date of January 1 of each year, and
file the Index Rate with the applicable regulatory authority. Subject to state requirements, small
group issuers are allowed to file subsequent submissions that reset the Index Rate for the
remaining quarters of the calendar year.
The purpose of the actuarial memorandum is to provide certain information related to the
submission, including support for the values entered into the Part I Unified Rate Review
Template, which supports compliance with the market rating rules and reasonableness of
applicable rate increases. All assumptions should be adequately justified with supporting data,
where possible, or other rationale for the use of the chosen assumptions.
While these instructions outline the minimum requirements, issuers are encouraged to provide
as much detail and supporting documentation as possible with their original submission to
potentially reduce the amount of time in review. Additional information will be required if,
given the facts and circumstances of the submission, the regulator determines that it is
necessary to properly complete its review of the rate submission.
The actuarial memorandum must also capture appropriate actuarial certifications related to:
• the methodology used to calculate the AV Metal Value for each plan
• the appropriateness of the essential health benefit portion of premium upon which
advanced payment of premium tax credits (APTCs) are based,
• the Index Rate is developed in accordance with federal regulations and the Index Rate
along with allowable modifiers are used in the development of plan specific premium
rates
State specific required information or certifications may also be included at the actuary’s
discretion. If an actuary chooses to exclude this information from the Part III Actuarial
Memorandum, this information would need to be provided to the state regulatory agency,
under separate cover.
In any case where information provided is not broadly applicable to all products and plans
included in the submission, please clearly indicate to which products and plans the information
applies.
ACA & MARKET RATING RULES ‐ ALLOWABLE RATING & PRICING
3
Allowable rating methods and factors
• The Single Risk Pool should include ALL (non‐grandfathered) covered persons (lives) an
issuer has in a state, within a market (individual, small group or combined). This
includes transitional products/plans for purposes of base rate experience used to
demonstrate the single risk pool. The projection period should reflect experience of
transitional policies to the extent the issuer anticipates the members in those policies
will be enrolled in fully ACA‐compliant plans during the projection period.
• The Index Rate is defined as the EHB portion of projected allowed claims divided by all
projected single risk pool lives. As a result, the Index Rate should be the same value for
ALL non‐grandfathered plans for an issuer in a state and market. This includes claims
and enrollment in transitional products/plans in the experience period and to the extent
an issuer anticipates the members in those policies will be enrolled in fully ACA‐
compliant plans during the projection period. Note that if an issuer opted to continue
policies under the President’s transitional memorandum, experience for these policies
should be included in the issuer’s 2013 experience for developing rates for the 2015
year. Appropriate adjustments should be made in Worksheet 1 – Section II of the
Unified Rate Review Template to bring these policies in line with all requirements of
non‐grandfathered policies projected in the Single Risk Pool in 2015. For example, in the
projection period, include projected experience and membership at the point when
these products become ACA‐compliant and membership renews to the ACA‐compliant
plan, or at a point when the members in these plans move to an ACA‐compliant plan, if
the plans are closed to new membership in 2015.
• The Market Adjusted Index Rate is the Index Rate adjusted for Risk Adjustment,
Reinsurance and Exchange Fees (with impacts and costs spread across the whole risk
pool). As a result, the Market Adjusted Index Rate should be the same value for ALL
non‐grandfathered plans for an issuer in a state and market.
• The Plan Adjusted Index Rate is the Market Adjusted Index Rate further adjusted for
plan specific factors allowed by 45 CFR Part 156.80(d)(2) such as provider network,
utilization management, benefits in addition to Essential Health Benefits (EHBs),
actuarial value and cost sharing, distribution and administrative costs (less Exchange
fees) and catastrophic plan eligibility variation.
• Note, fees and costs are included in the premium and applied at the plan level as part of
the distribution and administrative costs adjustment. The only exception is the
application of the Exchange User fees, which are applied at the market level to the Index
Rate. All other fees must be included in the development of the Plan Adjusted Index
Rate, prior to the application of member level rating factors, such as age factors. No
4
additional fees may be charged outside of the development of the Plan Adjusted Index
Rate. For example, if it costs an issuer $35 to process an application, that cost must be
included in the premium rate development of all policies (new issues and renewals) and
subject to the member level rating factors such as age and geographic region factors.
The issuer may not, in that example, charge a $35 fee per policy for submission of the
application.
• A calibration may be required to allow the rating factors to be directly applied in order
to generate the Consumer Adjusted Premium Rates.
For each allowable rating factor (i.e. age, geography, and tobacco) there is ONLY ONE
calibration allowed. That is, the calibration from the single risk pool to the allowable
rating factors may not vary by plan; it must be a common adjustment for all plans in a
state and market. The only allowable consumer level premium rate modifiers that can
be calibrated are age, geography and tobacco.
The calibration with respect to the age curve is allowed and identifies the value on the
age curve associated with the weighted average age on the standard age curve. The Plan
Adjusted Index Rate and the age curve can then be used to generate the schedule of
premium rates for all ages for each plan. Calibration may be required for the geographic
factors and tobacco factors. More detailed instructions are provided later in this
document regarding the requirements for the calibration.
It is important to note that the calibration process (described above) should ONLY occur
after the Plan Adjusted Index Rate has been determined, not at any point before. The
cost of all benefits (EHB and non‐EHB) and other expenses may not be charged to the
consumer using a flat dollar amount. All components under the plan must be part of the
premium charged. All components of the premium are subject to the consumer level
rating adjustments and therefore all components of the premium should likewise have
the calibration applied to them.
The result of this calibration process should be that the Plan Adjusted Index Rate
calibrated for geography and tobacco (but not age), multiplied by the geographic factor
for a given region should be similar to Premium Rate for that particular plan for a non‐
tobacco user in the given geographic region for the weighted average age (rounded to a
whole number) of the projected single risk pool.
• The Consumer Adjusted Premium Rate is the final premium rate for a plan that is
charged to an individual, family, or small employer group utilizing the rating and
premium adjustments as articulated in the applicable Market Reform Rating Rules. The
Consumer Adjusted Premium Rate is developed by calibrating the Plan Adjusted Index
Rate to the age curve as described above, calibrating for geography and tobacco if
necessary, and applying the allowable rating factors. Allowable rating factors are Age
5
(3:1 standard age curve or state specific age curve), Tobacco, Geography and Family
tiering/structure, unless otherwise prohibited by state law.
Once the Plan Adjusted Index Rate is calibrated to the age curve using the weighted
average age, the entire set of age rates is determined using the standard age factor of
each age relative to the standard age factor for the rounded weighted average age. The
age factors applied must be the standard age curve set by HHS or a state specific age
curve (if the state requires different age factors than the standard federal age curve).
The tobacco factors can be issuer specific but cannot vary by product/plan for an issuer
(i.e. an issuer must use the same tobacco factors across all products/plans within a state
and market).
Geographic rating areas are set specific to each state and all issuers in the state are
required to follow them and may only set one rating factor per rating area per state per
market and that factor is applied to all plans the issuer has in that rating area
uniformly. If an issuer has multiple networks within a given rating area and wants to
develop premiums specific for each network, the issuer must have a separate plan for
each network with the rating area.
Family structure takes into account family composition and the maximum of 3 child
dependents. This is further clarified in regulation that the premium for family coverage
is determined by summing the premiums for each individual family member, provided
at most three child dependents under age 21 are taken into account; this adjustment
does not result in a separate rating factor. Family tiering only occurs in states that use
pure community rating and are uniformly applied to all plans in the risk pool (and
published to the cciio.cms.gov website).
The following graphic depicts the flow of the rate development:
General Information
This section of the actuarial memorandum should include general information about the issuer
and the policies which are the subject of the submission. The information provided in this
section should include at least the following:
Company Identifying Information: State the following information that uniquely identifies the
issuer submitting the memorandum. The information must be the same as the entries in the
general information section of Worksheet 1 of the Part I Unified Rate Review Template (see the
instructions for the Part I Unified Rate Review Template for additional definition of these
fields):
6
• Company Legal Name: the organization’s legal entity name associated with the HIOS
Issuer ID
• State: the state that has regulatory authority over the policies
• HIOS Issuer ID: the HIOS ID assigned to the legal entity
• Market: the market in which the products and plans are offered
• Effective Date: the effective date of the change of the Index Rate
Company Contact Information: Provide the following information detailing how the reviewing
regulator should contact the company in the case additional information is needed.
• Primary Contact Name: Provide the name of the person at the company who will serve
as the primary contact for the submission. The regulator will contact this person if there
are questions related to the information submitted, or if additional information is
needed.
• Primary Contact Telephone Number: Provide the phone number for the primary
contact
• Primary Contact Email Address: Provide the email address for the primary contact
Proposed Rate Increase(s)
In this section the actuary must provide information related to the proposed rate increase(s). If
the proposed rate adjustment varies by product, the information provided should clearly
identify which proposed adjustments apply to which products. Include all products which are
part of the single risk pool, as defined by 45 CFR Part 156, §156.80, including those products for
which no rate adjustment is being proposed. The information that must be provided includes
the following items:
Reason for Rate Increase(s): Provide a narrative description of all significant factors driving a
proposed rate increase. As an example, these factors could include but are not limited to:
• Single risk pool experience which is more adverse than that assumed in the current
rates
• Medical inflation
• Increased utilization
• Prospective changes to benefits covered by the product or successor products
• New taxes and fees imposed on the issuer
7
• Anticipated changes in the average morbidity of the covered population that is market
wide, as opposed to issuer specific morbidity that is reflected in risk adjustment
• Anticipated changes in payments from and contributions to the Federal Transitional
Reinsurance Program
If the requested rate increase is not the same across all products and plans, provide a narrative
discussion as to why the rate changes vary by product or plan given they are based on the same
single risk pool of experience for the market.
Experience Period Premium and Claims
This section of the actuarial memorandum should include information related to the actuary’s
best estimate of premium and claims for the single risk pool during the experience period
reported in Worksheet 1, Section I of the Part I Unified Rate Review Template.
Paid Through Date: Indicate the date through which payments have been made on claims
incurred during the experience period.
Premiums (net of MLR Rebate) in Experience Period: Provide support for how the amount of
premium earned during the experience period, net of MLR rebates to policyholders, was
developed.
• Separately indicate the earned premium prior to MLR rebates and the amount of MLR
rebates refunded (or expected to be refunded) for the market during the experience
period. Earned premium should not be reduced for any reductions prescribed when
calculating the issuer’s MLR, such as taxes and assessments.
• For portions of the experience premium for which the MLR rebate has not been
finalized, a best estimate of the rebates is to be included. Describe the methodology
used to estimate such rebates.
Allowed and Incurred Claims Incurred During the Experience Period: Provide support for the
development of the actuary’s best estimate of allowed and paid claims incurred during the
experience period.
• Worksheet 1, Section I shows the actuary’s best estimate of the amount of claims that
were incurred during the 12‐month experience period. Separately indicate the amount
of claims which were processed through the issuer’s claim system, processed outside of
the issuer’s claims system, and the amount that represents the actuary’s best estimate
of claims incurred but not paid as of the Paid Through Date stated above. This should be
provided separately for Incurred Claims in Experience Period and Allowed Claims, as
defined and reported on Worksheet 1, Section I.
8
• Describe the method used for determining Allowed Claims. For example, Allowed Claims
could come directly from an issuer’s claim records or alternatively could be developed
by combining paid claims or capitation payments with member cost sharing.
• Provide support for the estimate of incurred but not paid claims
o Describe the methodology used to develop the estimate of claims incurred but
not paid for both Allowed Claims and Incurred Claims in Experience Period. To
the extent that the methodology or completion factors used to estimate
incurred but not paid claims on an allowed basis differs from the methodology or
completion factors used to estimate incurred claims, describe and support why
they are different.
o Indicate whether the claims used to develop any completion factors reflect the
experience period claims for the information submitted or some alternate claims
set, such as a larger block of the issuer’s experience. If an alternate claims set
was used, please provide support for why it is appropriate.
o If the incurred but not paid claims are unusually high or unusually low relative to
the experience period claims paid as of the Paid Through Date, explain what is
causing them to be unusually high or unusually low (e.g. introduction of a new
claims system, significant employee turnover, etc.)
Benefit Categories
For each of the Benefit Categories in Worksheet 1, Section II, describe the methodology used to
determine which category each claim in the experience period falls. For benefit categories
where “Other” was selected as the Utilization Description in the Part I Unified Rate Review
Template, please describe the measurement units that were used.
Projection Factors
This section should include a description of each factor used to project the experience period
allowed claims to the projection period, and supporting information related to the
development of those factors. For each factor, the actuary should include a description of the
source data or assumptions used, why they are appropriate for the single risk pool, and any
applicable adjustments made to the data, such as considerations for issuer specific experience,
industry or internal studies, benefit design and credibility of the source data. At a minimum,
include support for the following factors:
Changes in the Morbidity of the Population Insured: Describe any adjustment factors applied
to the experience period claims to account for anticipated differences in the average morbidity
of the pooled population underlying the experience period and the issuer’s population
anticipated to be insured in the projection period. These adjustments are shown in the “Pop’l
risk Morbidity” column on Worksheet 1, Section II, and are in addition to the anticipated
change in claims cost as a result of changes in the average mix by age and gender of the
9
covered population (which are shown in the “Other” adjustment column). The morbidity of the
population could be impacted by items such as guarantee issue, an individual mandate to
maintain coverage, expansion of Medicaid programs, and the introduction of a Basic Health
Program.
Changes in Benefits: Describe the development of factors used to adjust the experience period
claims to reflect the average benefits that will be covered during the projection period,
including any newly mandated benefits. These changes are reflected in the “Other”
adjustments column on Worksheet 1, Section II. The factors could adjust for items including but
not limited to the following:
• Addition of any benefits that must be covered under the essential health benefit
package
• Any newly mandated benefits required under state law that are not reflected in the
experience period claims
• Adjustment for the removal of benefits covered in the experience period claims that will
not be covered in the projection period
• Anticipated changes in the average utilization of services due to differences in average
cost sharing requirements during the experience period and average cost sharing
requirements in the projection period
Changes in Demographics: Describe the development of factors used to adjust the experience
period claims to reflect differences between the average mix of the population by age, gender,
and region underlying the base period experience and the average mix anticipated to underlie
the projection period. These changes are reflected in the “Other” adjustments column on
Worksheet 1, Section II. Describe and support the age/gender factors underlying the
development of these claims‐based demographic adjustment factors.
Other Adjustments: Describe any other adjustments, in addition to benefits and demographics
which are specifically addressed above, that are reflected in the “Other” adjustments column
on Worksheet 1, Section II. Also describe how these factors were developed.
Trend Factors (cost/utilization): Describe the source claims data used and methodology used
for developing the cost and utilization projection factors, including all adjustments made to the
data. Explain why the adjusted source data is applicable to the single risk pool. Some examples
of such adjustments include but are not limited to the following:
• Normalization for changes in age
• Normalization for benefit changes that occurred during the period (Even if allowed
claims are used to project trend a normalization adjustment may be warranted to
account for the influence that changes in benefits have on utilization.)
10
• Adjustments for seasonality patterns underlying the claims that may skew calculated
trends
• Normalization for any one‐time events which are not anticipated to reoccur during the
projection period
• Adjustments for anticipated changes in provider contracts that differ from those
underlying the experience used
• For prescription drugs, any adjustments made to account for changes in the formulary,
expiration of patents, or introduction of new drugs
Credibility Manual Rate Development
For issuers with experience period claims that are not determined to be fully credible, the use
of other credible claims experience must be employed in developing a credibility manual rate
for blending with the experience period claims. The actuary must provide information related
to the other experience and general methodology used in developing the manual rate.
Source and Appropriateness of Experience Data Used: Describe the source data used to
develop the manual rate and why such data is appropriate. Sources considered reasonable for
developing manual rates include but are not limited to:
• Multiple years of experience for the market for which rates are being submitted
• The issuer’s experience for similar policies nationwide, including rationale for
inclusion/exclusion of various blocks of business
• A manual rate developed by a consultant with appropriate supporting documentation as
to the underlying source data for development of the manual rate
Adjustments Made to the Data: The experience upon which the manual rate is based must be
adjusted to be reflective of the population, region, provider network, and benefits anticipated
under the policies for which rate increases are being submitted. Describe all adjustments made
to the data underlying the development of the manual rate to account for differences in
demographics, benefits and morbidity/risk to ensure that that resulting manual rate is
appropriate for blending with the adjusted experience period claims.
Inclusion of Capitation Payments: If some of the services in the projection period will be
provided under a capitation arrangement, specifically describe how these payments were
accounted for in the development of the credibility manual.
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Credibility of Experience
In this section issuers must provide support for the credibility level assigned to their base
period experience, with the complement being applied to a credibility manual. The requested
information will include items such as:
• Description of the Credibility Methodology Used
• Resulting Credibility Level Assigned to Base Period Experience when applying the
proposed credibility methodology.
When the base period experience is partially credible and included in experience used to develop
the manual rate, the actuary must consider the extent to which the manual rate development
double counts the base period experience. If the proposed manual rate lacks sufficient
independence from the base period experience, the credibility percentage in the template should
be adjusted such that the experience is assigned the appropriate credibility (based on the issuer’s
credibility formula), taking into consideration the proportion of the manual experience that is from
the subject base experience. In this case additional documentation should be included in the
actuarial memorandum to demonstrate that the credibility factor applied in the template is
consistent with the issuer’s credibility formula.
When determining credibility, the actuary should consider Actuarial Standard of Practice #25,
“Credibility Procedures Applicable to Accident and Health, Group Term Life, and
Property/Casualty Coverages.”
Paid to Allowed Ratio
Provide support for the Paid to Allowed Average Factor in Projection Period for the market,
shown in Worksheet 1, Section III. Demonstrate that the ratio is consistent with membership
projections by plan included in Worksheet 2. The ratio for each plan should be relatively
consistent with the metallic actuarial value for the plan to which the actuary is attesting,
however it is recognized that they may not be exactly the same due to differences between the
issuer’s experience and the experience underlying the AV Calculator.
Risk Adjustment and Reinsurance
This section includes information related to the experience and methodology used to estimate
risk transfer payments and charges, and reinsurance amounts that are incorporated in
Worksheet 1, Section III and Worksheet 2, Sections III (if applicable) and IV.
Projected Risk Adjustments PMPM:
Under the single risk pool pricing requirements issuers are required to make a market wide
adjustment to the pooled market level Index Rate to account for federal risk adjustment and
reinsurance payments. Consistent with this adjustment, anticipated risk adjustment revenue
must be allocated proportionally based on plan premiums for all plans within a risk pool by
12
applying the risk adjustment transfer adjustment factor as a constant multiplicative factor
across all plans. The risk adjustment transfer amount should be net of the risk adjustment fees.
In the Part III Actuarial Memorandum issuers must explain how they developed their estimated
risk adjustment revenue for all of the plans in the risk pool. Issuers are expected to explain all of
their market and plan level assumptions related to the inputs of the HHS payment transfer
formula (or alternative state payment transfer formula, if applicable). In other words, issuers
must explain their assumptions related to plan and market level risk scores and other relevant
cost factor adjustments that are used to calculate payment transfers under the risk adjustment
program. Issuers should explain any potential outlier assumptions that have a significant impact
on transfers. Issuers may elect to provide supplemental exhibits detailing their plan level
transfer calculations in order to demonstrate that their transfer estimates appropriately track
with the HHS payment transfer formula.
Issuers must also explain how anticipated risk adjustment transfer revenue was allocated to
plan premiums in the risk pool (as noted above transfers must be allocated proportionally
based on plan premium). Issuers should describe the overall impact of risk adjustment transfers
on premiums.
Projected ACA Reinsurance Recoveries Net of Reinsurance Premium (Individual Market and
Combined Markets Only):
Under the single risk pool pricing requirements issuers are required to make a market wide
adjustment to the pooled market level Index Rate to account for federal risk adjustment and
reinsurance payments. Consistent with this adjustment, anticipated reinsurance revenue must
be allocated proportionally based on plan premiums for all plans within a risk pool by applying
the reinsurance adjustment factor as a constant multiplicative factor across all plans.
The Part I Unified Rate Review template requires issuers to report reinsurance payments net of
reinsurance contributions. Issuers must describe the underlying experience data and
assumptions that they used to develop their estimates of both reinsurance contributions and
payments. In particular, issuers should provide an explanation of how they developed an
estimate of their claims liability between the reinsurance attachment point and cap. Issuers
should describe any key aspects of their enrolled population that significantly impacted their
claims assumptions.
Issuers must also describe how they allocated their anticipated reinsurance payments net of
reinsurance contributions across the plans in their risk pool (as noted above reinsurance
revenue should be allocated proportionally based on premium). Issuers may provide
supplemental exhibits that demonstrate how they estimated plan level reinsurance payments
in order to demonstrate that they appropriately track with the Federal methodology for
calculating reinsurance payments.
As only non‐grandfathered policies in the individual market are eligible for payments under the
transitional reinsurance program, in a combined market, the pooled reinsurance adjustment
should be based only on the portion of the issuer’s combined market business eligible for
13
reinsurance payments. Further, the transitional reinsurance program does not apply to policies
renewed under the special transition policy.
State the assumed amount of the assessment as a PMPM amount.
Non‐Benefit Expenses and Profit & Risk
Administrative Expense Load: Provide support for all expenses that do not reflect payments
made to providers under the contract for covered medical services. Describe the methodology
used for developing the estimate of these non‐benefit expenses expected during the projection
period for the applicable market, including any allocation of corporate overhead. Discuss how
the percentage load varies by product or plan, if applicable. Describe the source data that was
used as a basis for the projections and why that data is appropriate.
For reporting purposes, the Administrative Expense Load should not include the Profit & Risk
Load or the Taxes & Fees load, both described below, even though they are considered
administrative expenses for the purposes of adjusting the Index Rate to arrive at premium in
the pricing process.
It is suggested that the issuer maintain documentation of the expense allocation methodology,
including expenses identified by function and whether they are fixed or variable, so that it can
be made readily available to the regulator upon request.
Profit (or Contribution to Surplus) & Risk Margin: Describe the target underwriting gain/loss
margin, and any additional risk margin. To the extent that the target as a percent of premium
has changed from the prior submission, provide additional support for why the change is
warranted. Discuss how the percentage load varies by product or plan, if applicable.
Note that for pricing purposes, Profit & Risk Load is considered part of administrative expenses,
per 45 CFR Part 156, §156.80(d). It is described separately in the actuarial memorandum to
facilitate rate review.
Taxes and Fees: Describe each tax and/or fee and indicate the amount for each, either as a
percent of premium or a per member per month amount. Describe only the taxes and fees that
may be subtracted from premiums for purposes of calculating MLR. However, do not include
any contributions to the Federal transitional reinsurance program or risk adjustment user fees
in this amount despite their treatment in MLR calculations, since Federal reinsurance and risk
adjustment are expressed in the template net of reinsurance premium and risk adjustment user
fees. Any additional taxes and fees should be reflected in the Administrative Expense Load.
Note that for pricing purposes, Taxes & Fees (including Exchange user fees) are considered part
of administrative expenses, per 45 CFR Part 156, §156.80(d). It is described separately in the
actuarial memorandum to facilitate rate review.
Exchange user fees should be included in the template in Taxes and Fees. The issuer should
provide a narrative verifying the exchange user fees are applied as an adjustment to the Index
14
Rate at the market level. A description of the process the issuer used to calculate the
adjustment should be included. The value should reflect the expected mix of exchange and
non‐exchange enrollees.
Projected Loss Ratio
Indicate the projected loss ratio using the Federally prescribed MLR methodology. If the
projected loss ratio is less than 80%, explain your plan to comply with the Federal MLR
requirement found in PHSA 2718.
If the state requires a projected loss ratio demonstration, then such a demonstration should
also be included.
Single Risk Pool
The issuer is required to provide support that the Single Risk Pool for in a particular state and
market is established according to the requirements in 45 CFR part 156, §156.80(d). The Single
Risk Pool reflects all covered lives for every non‐grandfathered product/plan combination for
an issuer in a state and market. The Single Risk Pool is specific to the legal entity for the state
and market for which it is submitted.
The Single Risk Pool should include transitional products/plans for purposes of base rate
experience used to demonstrate the single risk pool. The projection period should reflect
experience of transitional policies to the extent the issuer anticipates the members in those
policies will be enrolled in fully ACA‐compliant plans during the projection period.
Index Rate
The issuer is required to provide support for the development of the Index Rate in both the
experience period and the projection period. The Index Rate is specific to the legal entity for the
state and market for which it is submitted. The Index Rate represents the estimated total
combined allowed claims experience PMPM in the Single Risk Pool, and should not be adjusted
for payments and charges under the risk adjustment and reinsurance programs, or for Exchange
user fees.
The Index Rate is to be developed following the specifications of 45 CFR part 156.80(d)(1). The
Index Rate is based on the total combined claim costs for providing the EHBs for the Single Risk
Pool of that state market. The Index Rate is derived by dividing the total combined EHB allowed
claims for the Single Risk Pool by all covered lives in the Single Risk Pool of that state market.
Issuers must establish a single Index Rate for all product/plan combinations in the Single Risk
Pool.
Issuers are required to provide detailed documentation of the development of the Index Rate in
the Actuarial Memorandum.
15
Describe the difference between the total allowed claims PMPM and the Index Rate. For
example, describe any covered benefits in excess of essential health benefits that are included
in allowed claims but excluded from the Index Rate.
For Part I Unified Rate Review Template submissions with an Experience Period Start Date of
January 1, 2014 or later, it is expected that the Index Rate of the Experience Period reported in
Worksheet 1 be consistent with the Experience Period Allowed Claims PMPM. While these two
amounts may not be identical due to the inclusion of non‐EHB services in the Experience Period
Allowed Claims PMPM, which would not be included in the Index Rate of the Experience Period,
it is anticipated that these amounts would be developed on a consistent basis.
For Part I Unified Rate Review Template submissions with an Experience Period Start Date prior
to January 1, 2014, provide the methodology used to develop the reported Index Rate of
Experience Period. Describe how claims for benefits which were covered during the experience
period but are not essential health benefits were identified and removed.
If the submission is for the individual or combined market, the Index Rate for Projection Period
should reflect the twelve month projection period shown on Worksheet 1, Section II. If the
submission is for the small group market and includes prospective trend adjustments (only if
permitted by the state), then the Index Rate for Projection Period should reflect the member
weighted average of the projected Index Rates applicable for each effective date in the
submission. Show the projected trended Index Rate for each effective date in the submission.
The projected Index Rate must reflect the anticipated claim level of the projection period with
respect to trend, benefit and demographics. It must reflect the experience of all policies
expected to be in the single risk pool (with all necessary adjustments to reflect the benefits,
market rules, etc. applicable to policies upon issue or renewal during the projection period). For
transitional policies, the issuer should include those policies anticipated to be enrolled in a fully
ACA‐compliant during the projection period at a point when the members in these plans move
to an ACA‐compliant plan. If an issuer wants the renewal rates to increase with trend in the
small group market as allowed by the state regulatory authority, the issuer may file the quarterly
trend amounts for the twelve month period at one time. The quarterly trend factors applied to
the issuer’s rates should be included in the Part III Actuarial Memorandum. The Appendix to the
Instructions for the Part I Unified Rate Review Template provides further guidance.
The Index Rate may only change at uniform intervals. All issuers are required to set the Index
Rate for an effective date of January 1 of each year, and file the Index Rate with the applicable
regulatory authority. Subject to state requirements, small group issuers are allowed to file
subsequent submissions that reset the Index Rate for the remaining quarters of the calendar
year.
For individual and combined market exchanges this will be annually. It is anticipated that
Issuers in the small group market will be able to file for quarterly Index Rate changes starting
with the third quarter of 2014.
16
While rate adjustments for the small group market may be filed on a quarterly basis (if
permitted by the state), these interim filings could include adjustments for other items, such as
new products, more recent experience period claims, etc. However, the rate development for
these interim filings must be based on the single risk pool. For example, take an issuer with two
cohorts of small employers that files on an interim quarterly basis. The small employers with
young enrollees renew in January, while the small employers with older enrollees renew in
April. The issuer’s Index Rate in the applicable submissions would be derived as follows
(assuming the same experience period is used for the two submissions with no projected
changes to the population between the experience period and the projection period):
January effective date
April effective date
Total Single Risk Pool
Member Months
(2012)
1000
1000
2000
Base Allowed Claims
(2012) PMPM
$250
$400
$325
Months of Trend
24
27
Annual Trend Rate
5%
5%
Single Risk Pool
Projected Allowed
Claims
(=$325*(1+Annual
Trend)^(Months of
Trend/12))
$358.31
$362.71
Index Rate
$358.31
$362.71
As shown in the table above, the projected Index Rate is based on the weighted average claims,
benefit mix, demographic mix, etc. of the entire single risk pool, even if it is only submitted to
be effective for a portion of the single risk pool (e.g., one quarter of renewals).
As described above, small group issuers may have the ability to file Part I Unified Rate Review
Templates subsequent to the annual filing that resets the Index Rate for the remaininq quarters
of the calendar year. However, the change in the Index Rate is only allowed to occur for the
remainder of the calendar year and subsequent submission is required at the beginning of the
next calendar year.
For example, if a small group issuer submits the Part I Unified Rate Review Template for
January 1, they may submit a subsequent Part I Unified Rate Review Template that
resets the Index Rate effective July 1 of that same year. The Part I Unified Rate Review
Template effective July 1 in this example is only allowed to contain a trend increase for
17
October 1 of that same year. Quarters after October 1 would be included in the next
annual submission effective January 1 of the next calendar year.
Market Adjusted Index Rate
Issuers are required to include the Market Adjusted Index Rate.
The Market Adjusted Index rate is calculated as the Index Rate adjusted for all allowable
market‐wide modifiers defined in the market rating rules, 45 CFR Part 156, §156.80(d)(1). The
following market‐wide adjustments to the Index Rate are allowable under these rules:
• Federal reinsurance program adjustment (market‐wide adjustment)
• Risk adjustment (market‐wide adjustment)
• Exchange user fee adjustment (market‐wide adjustment)
The issuer is required to provide an explanation of how these modifiers are developed and
applied to the Index Rate to develop the Market Adjusted Index Rate. Similar to the Index Rate,
the Market Adjusted Index Rate reflects the average demographic characteristics of the single
risk pool. In other words, the Market Adjusted Index Rate is not calibrated.
However, the Market Adjusted Index Rate is not included in the Part I Unified Rate Review
Template in 2015.
Plan Adjusted Index Rates
The Plan Adjusted Index Rates are included in Worksheet 2, Section IV of the Part I Unified Rate
Review Template in 2015.
The Plan Adjusted Index Rate is calculated as the issuer Market Adjusted Index Rate adjusted
for all allowable plan level modifiers defined in the market rating rules, 45 CFR Part 156,
§156.80(d)(2). The following adjustments are allowable under these rules:
• Actuarial value and cost sharing adjustment (plan adjustment)
• Provider network, delivery system and utilization management adjustment (plan
adjustment)
• Adjustment for benefits in addition to the EHBs (plan adjustment)
18
• Impact of specific eligibility categories for the catastrophic plan (plan
adjustment)
• Adjustment for distribution and administrative costs (plan adjustment)
The issuer is required to provide an explanation of how these modifiers are developed and
applied to the Market Adjusted Index Rate to derive the Plan Adjusted Index Rate. Note, fees
and costs are included in the premium and applied at the plan level as part of the distribution
and administrative costs adjustment. The only exception is the application of the Exchange User
fees, which are applied at the market level to the Index Rate. All other fees must be included in
the development of the Plan Adjusted Index Rate, prior to the application of member level rating
factors, such as age factors. No additional fees may be charged outside of the development of
the Plan Adjusted Index Rate. For example, if it costs an issuer $35 to process
an application, that cost must be included in the premium rate development of all policies (new
issues and renewals) and subject to the member level rating factors such as age and geographic
region factors. The issuer may not, in that example, charge a $35 fee per policy for submission of
the application.
Specifically for the catastrophic plan rate, describe the methodology used to estimate the
adjustment reflecting differences in anticipated demographics and morbidity of the
catastrophic population as compared to the single risk pool.
Similar to the Index Rate and Market Adjusted Index Rate, the Plan Adjusted Index Rates reflect
the average demographic characteristics of the single risk pool. In other words, the Plan
Adjusted Index Rate is not calibrated.
Calibration
Issuers may need to calibrate the Plan Adjusted Index Rates (which are based on the single risk
pool) to apply the allowable rating factors (i.e. age, geography, and tobacco) in order to
calculate Consumer Adjusted Premium Rates. The calibration for each allowable rating factor is
described below. It is important to note that there is ONLY ONE calibration value which is
applied to all Plan Adjusted Index Rates. That is, the calibration may not vary by plan; it must be
a common value to all plans in a state and market. Each calibration should be performed using
a unique weighting; i.e., the geographic weighting will differ from the age weighting for
determining the calibration factor. Once the calibration factor is determined it must be applied
uniformly to all plans in a market and state.
Age Curve Calibration
Issuers must provide the approximate weighted average age, rounded to a whole number,
associated with the projected single risk pool in the Actuarial Memorandum.
19
Issuers must provide a detailed explanation of the methodology used in the calibration to the
age curve. Specifically, issuers should describe the factors used in the determination of the risk
pool weighted average age, a description of data used to weight the factors and a description of
the exact calculation. Issuers will need to provide actuarial justification that the methodology
employed in the calculation of the average age and the calibration to the age curve complies
with the standard age curve methodology and that it conforms with the rating rules specified in
45 CFR 147.102.
A demonstration of how the the Plan Adjusted Index Rate and the age curve are used to
generate the schedule of premium rates for each plan should be included in the Actuarial
Memorandum. Note, the age curve calibration adjustment is not plan specific. In other words,
the same age curve calibration must be applied to all plans in the projected single risk pool.
Geographic Factor Calibration
The issuer is required to include a listing of all geographic rating factors applied to the Plan
Adjusted Index Rate in the Actuarial Memorandum.
The issuer must provide the geographic factor calibration that is applied to the projected single
risk pool if one is necessary. For example, if the weighted average of the geographic factors
does not equal 1.0, calibration may be required.
A detailed description of the development of the geographic rating factors and a demonstration
of how these factors are applied to the Plan Adjusted Index Rate is to be included in the
Actuarial Memorandum. For example, if the weighted average of the geographic factors does
not equal 1.0, the calibration adjustment that is applied should be included in the Actuarial
Memorandum along with documentation of the calculation of the calibration adjustment. Note,
the geographic calibration adjustment is not plan specific. In other words, the same geographic
calibration would be applied to all plans in the projected single risk pool. If an issuer has
multiple networks within a given rating area and wants to develop premiums specific for each
network, the issuer must have a separate plan for each network with the rating area.
Tobacco Calibration
The issuer is required to include a listing of all tobacco rating factors applied to the Plan
Adjusted Index Rate in the Actuarial Memorandum.
If the issuer uses tobacco factors, as allowed, the issuer must provide the tobacco calibration
that is applied to the projected single risk pool.
A detailed description of the development of the tobacco rating factors and a demonstration of
how these factors are applied to the Plan Adjusted Index Rate should be included in the
Actuarial Memorandum. Note, the tobacco calibration adjustment is not plan specific. In other
20
words, the same tobacco calibration would be applied to all plans in the projected single risk
pool.
The calibration adjustments are to be applied uniformly to all plans; plan specific calibration
is not allowed.
Calibration adjustments are not found in the Part I Unified Rate Review Template in 2015.
Once the Plan Adjusted Index Rate is calibrated to the age curve using the weighted average
age, the entire set of age rates is determined using the standard age factor of each age relative
to the standard age factor for the rounded weighted average age. The age factors must be the
standard age curve set by HHS or a state specific age curve (if the state requires different age
factors than the standard federal age curve).
Issuers that calibrate the Plan Adjusted Index Rate as described in the previous section must
calibrate the plans to in the Single Risk Pool consistently; in other words the calibration cannot
vary by plan.
Issuers must apply these consumer level adjustments as described in §147.102 uniformly to all
plans in the Single Risk Pool; these adjustments cannot vary by plan.
Consumer Adjusted Premium Rate Development
The Consumer Adjusted Premium Rate is the final premium rate for a plan that is charged to an
individual, family, or small employer group utilizing the rating and premium adjustments as
articulated in the applicable Market Reform Rating Rules. The Consumer Adjusted Premium
Rate is developed by calibrating the Plan Adjusted Index Rate to the age curve as described
above, calibrating for geography and tobacco if necessary, and applying the rating factors
specified by 45 CFR Part 147, §147.102. The following adjustments are allowable under this
rule:
• Whether the plan coverage covers an individual or family (issuers must cover any
eligible individual and/or eligible family that requests coverage per the
guaranteed issue requirement of the ACA); this is further clarified in regulation
that the premium for family coverage is determined by summing the premiums
for each individual family member, provided at most three child dependents
under age 21 are taken into account; this adjustment does not result in a
separate rating factor
• Rating area
• Age – reflecting the applicable age curve
• Tobacco status
21
The Actuarial Memorandum should describe how each allowable consumer level adjustment is
applied to the Plan Adjusted Index Rate so that the reviewing actuary can readily use the
information to approximate Consumer Adjusted Premium Rates filed by the issuer.
The Consumer Adjusted Premium Rates are not included in the Part I Unified Rate Review
Template in 2015.
Small Group Plan Premium Rates
If an issuer files small group rates with trend, the Index Rate, the Market Adjusted Index Rate
and the Plan Adjusted Index Rate reflect the member weighted average premium over the
calendar year (see example in the Appendix of the instructions to the Part I Unified Rate Review
Template). As such, in the development of the Consumer Adjusted Premium Rates for small
group plans in this case, the Plan Adjusted Index Rate must be adjusted to reflect the
appropriate quarter when the consumer level modifiers are applied. Issuers should provide the
trend factors that apply to the weighted average Plan Adjusted Index Rates to develop the rates
for each effective date included in the submission.
AV Metal Values
The issuer must describe whether the AV Metal Values included in Worksheet 2 of the Part I
Unified Rate Review Template were entirely based on the AV Calculator, or whether an
acceptable alternative methodology was used to generate the AV Metal Value of one or more
plans. If an alternate methodology was employed to develop the AV Metal Value(s), the actuary
must provide a copy of the actuarial certification required by 45 CFR Part 156, §156.135. The
certification must be signed by a member of the American Academy of Actuaries, and must
indicate that the values were developed in accordance with generally accepted actuarial
principles and methodologies.
The actuary must indicate the reason an alternate methodology was used, explain why the
benefits for those plans for which an acceptable alternative methodology was used are not
compatible with the AV Calculator, and state the chosen alternate methodology that was used
for each applicable plan. The actuary must describe the process that was used to develop the
AV Metal Value.
Actuaries are encouraged to refer to applicable practice note(s) for guidance on alternate
methods of calculating actuarial value.
AV Pricing Values
For each plan, indicate the portion of the AV Pricing Value that is attributable to each of the
allowable modifiers to the Index Rate, as described in 45 CFR Part 156, §156.80(d)(2). If the
adjustment for plan cost‐sharing includes any expected differences in utilization due to these
differences in cost sharing, describe in detail how the difference was estimated and how the
methodology ensures that differences due to health status are not included in the adjustment.
22
Membership Projections
Describe how the membership projections found in Worksheet 2 of the Part I Unified Rate
Review Template were developed. Items impacting these projections could include but are not
limited to changes in the size of the market due to introduction of guarantee issue
requirements (individual market), the individual mandate, expansion of Medicaid, and the
introduction of a Basic Health Program.
Describe any differences between the distribution of projected member months relative to the
current membership distribution.
For Silver level plans in the individual or combined markets, describe the methodology used to
estimate the portion of projected enrollment that will be eligible for cost sharing reduction
subsidies at each subsidy level. State the resulting projected enrollment by plan and subsidy
level.
Terminated Products
List the name of each product that will be terminated prior to the effective date. Include both
products that have experience included in the single risk pool during the experience period and
any products that were not in effect during the experience but were made available thereafter.
Plan Type
In the event that the plan types listed in the drop‐down box in Worksheet 2, Section I of the
Part I Unified Rate Review Template do not describe an issuer’s plan exactly and the issuer has
selected the closest plan available, per the instructions, please describe the differences
between the issuer’s plan and the plan type selected.
Warning Alerts
Describe any difference between the sum of the plan level projections in Worksheet 2 and the
total projected amounts found on Worksheet 1. These differences are indicated by Warning
Alerts in Worksheet 2.
Effective Rate Review Information (optional)
45 CFR Part 154 §154.301 describes the elements of an effective rate review program. There
are elements of an effective rate review for which the data needed to perform the review is not
explicitly shown on the Part I Unified Rate Review Template, e.g., the health insurance issuer’s
capital and surplus. Issuers may optionally provide additional information to facilitate an
effective review of the submitted rate increase(s). While this information is optional, it is noted
that providing the information with the initial submission reduces the likelihood of the reviewer
requesting supplemental information during the course of the rate review. In addition, states
may have additional data requirements. Additional state‐required data may be submitted with
the submission, or it may be provided to the state separately.
23
Reliance
If, in preparing the Part I Unified Rate Review Template submission, the certifying actuary relied
on any information or underlying assumptions provided by another individual, the information
relied upon and the name of the individual providing that information may be disclosed.
Actuarial Certification
An actuarial certification must be provided for the following:
• the methodology used to calculate the AV Metal Value for each plan,
• the appropriateness of the essential health benefit portion of premium upon which
advanced payment of premium tax credits (APTCs) are based, and
• the Index Rate is developed in accordance with federal regulations and the Index Rate
along with allowable modifiers are used in the development of plan specific premium
rates.
State specific required information or certifications may also be included at the actuary’s
discretion. If an actuary chooses to exclude this information from the Part III Actuarial
Memorandum, this information would need to be provided to the state regulatory agency
under separate cover.
The opining actuary must be a member of the American Academy of Actuaries, in good
standing, and have the education and experience necessary to perform the work. The actuary
must develop rates in accordance with the appropriate Actuarial Standards of Practice (ASOPs)
and the profession’s Code of Professional Conduct. While other ASOPs apply, particular
emphasis is placed on the following:
• ASOP No. 5, Incurred Health and Disability Claims
• ASOP No. 8, Regulatory Filings for Health Plan Entities
• ASOP No. 12, Risk Classification
• ASOP No. 23, Data Quality
• ASOP No. 25, Credibility Procedures Applicable to Accident and Health, Group Term Life,
and Property/Casualty Coverages
• ASOP No. 26, Compliance with Statutory and Regulatory Requirements for the Actuarial
Certification of Small Employer Health Benefit Plans
• ASOP No. 41, Actuarial Communications
At a minimum, the actuarial certification must include the following:
1. Identification of the certifying actuary and a statement that he/she is a member of the
American Academy of Actuaries
24
2. A certification that the projected Index Rate is:
a. In compliance with all applicable State and Federal Statutes and Regulations (45
CFR 156.80(d)(1)),
b. Developed in compliance with the applicable Actuarial Standards of Practice
c. Reasonable in relation to the benefits provided and the population anticipated
to be covered
d. Neither excessive nor deficient
3. A certification that the Index Rate and only the allowable modifiers as described in 45
CFR 156.80(d)(1) and 45 CFR 156.80(d)(2) were used to generate plan level rates.
4. A certification that the percent of total premium that represents essential health
benefits included in Worksheet 2, Sections III and IV were calculated in accordance with
actuarial standards of practice.
5. A certification stating that the AV Calculator was used to determine the AV Metal Values
shown in Worksheet 2 of the Part I Unified Rate Review Template for all plans except
those specified in the certification. If an alternate methodology was used to calculate
the AV Metal Value for at least one plan offered, a copy of the actuarial certification
required by 45 CFR Part 156, §156.135 must be included. The certification must be
signed by a member of the American Academy of Actuaries, and must indicate that the
values were developed in accordance with generally accepted actuarial principles and
methodologies.
For purposes of rate review, also include the reason an alternate methodology was
used, and the chosen alternate methodology that was used for each applicable plan.
Describe the process that was used to develop the AV metal value.
The actuary may qualify the opinion, if desired, to state that the Part I Unified Rate Review
Template does not demonstrate the process used by the issuer to develop the rates. Rather it
represents information required by Federal regulation to be provided in support of the review
of rate increases, for certification of qualified health plans for Federally facilitated exchanges
and for certification that the Index Rate is developed in accordance with Federal regulation and
used consistently and only adjusted by the allowable modifiers.
Attachment 4
Benefits Map
INSTRUCTIONS AND NOTES ON BENEFIT DOCUMENTATION
1
The purpose of the Benefits Map is to codify the principal elements that define each benefit package offered by the carrier
to the Small Group and Individual markets. In most cases, cells have been limited to a pre‐determined drop‐down menu of
selected values to promote uniformity among plan descriptions.
If more than three plans are offered please add additional tabs
2
The term Cost‐Sharing applies to the mechanism by which member out‐of‐pocket contribution is determined, according
to the type of service being rendered. Basic cost‐sharing can be in the form of copayments (i.e. fixed dollar amounts),
coinsurance (i.e. a fixed percentage of the cost of services), or front‐end deductibles where the member covers 100% of
the cost of services up to the defined deductible amount, after which point plan coverage begins. More complex cost‐
sharing can be in the form of mixed coinsurance and copayments, where minimum and maximum dollar amounts are in
place around a base coinsurance amount (e.g. 20% coinsurance with a minimum $15 copayment, or 25% coinsurance with
a maximum copayment amount of $300).
3
In some plan designs, reduced cost‐sharing is available in the medical coverage if certain preferred facilities are utilized.
If this is the case, indicate so by selecting 'Y' (yes) under the column 'Preferred Facility Y or N ' for the specified service
category, and then enter the reduced cost‐share ($ or %) in the 'Preferred Facility Copay ' column beside the 'Y.'
4
For purposes of the Benefits Map, in order to indicate that a certain benefit is NOT COVERED, or that the member is in a
Deductible Phase (as in the case of Rx Coverage with a front‐end deductible), the Member Cost‐Share should reflect
COINSURANCE of 100% (i.e. the member pays 100% of the cost).
5
Some plan designs may contain a feature, such as a Major Medical rider, which allows the member to submit for reimburse‐
ment amounts paid for services rendered by non‐participating providers. Some of these riders limit reimbursement to
services rendered in Puerto Rico while others include services rendered in the United States. The Benefits Map allows
plans to indicate whether they include such a rider, whether or not they cover U.S. services, and whether those services
require prior authorization. Typically these riders carry an annual front‐end deductible per individual (with a maximum
deductible per family covered), followed by cost‐sharing based on a defined member coinsurance amount. Often these
riders contain a provision which caps member cost‐sharing to an annual Out‐of‐Pocket Maximum , defined both at the
individual and family contract levels.
6
Plans that cover Dental Services may carry Overall Annual Benefit Limits (General Annual Limits ) and/or specific Category
Lifetime Limits (such as for Orthodontia). Please indicate such limits as they may apply in the Dental Coverage section.
7
In the case of Prescription Drug Coverage, plans should indicate which rule applies to the dispensing of brand drugs which
have a generic bioequivalent substitution (i.e. Multi‐Source Brand Drugs). Select 'Generics Not Mandatory ' if members are
not required to select a generic medication as a first option. Select 'Dispense As Written (D.A.W.)' if the member is required
(via a copay penalty) to select generics as a first option, but where such penalty is waived if the physician indicates "Do Not
Substitute" on the prescription. Select '$ Penalty + Generic Copay' if members are required to select generics as a first option
(regardless of physician indications) or pay a copay penalty (usually the difference in price between the generic and brand
versions), plus the amount of the generic copayment. If instead the amount of the penatly is added to the BRAND copay,
then select '$ Penalty + Brand Copay .'
8
Indicate other features of the Prescription Drug Coverage such as whether Step Therapy and/or Drug Formularies apply, and
whether OTC medications are covered, along with the corresponding copay.
9
Since many prescription drug plan designs offer different levels of coverage at different expenditure levels throughout the
policy year, the Benefits Map provides for up to three (3) different benefit phases in order to codify such plan designs. For
example, a complex plan design may carry a $500 front‐end deductible before benefits kick in, later providing benefits at $5
$5 for generics and $15 for brand drugs up until $2,000 in annual expenditures. After that point, the plan design may only
cover 50% of the cost of brand drugs, while covering generics with a flat copay of $15. The Benefits Map provides the neces‐
sary paramaters to codify this design by indicating 100% coinsurance (no coverage) in Phase I from $0 to $500, indicating $5
Generic and $15 Brand in Phase II from $500 to $2,000, and finally indicating $15 Generic and 50% coinsurance for Brand in
Phase III from $2,000 to $99,999. Note: The limit of $99,999 indicates that the given Rx benefit phase has no limit.
Attachment 4
Benefits Map
UNIFORM PLAN DESIGN TEMPLATE
Drop‐Down Menu Items
Carrier Name:
Incurred Experience Period:
VALUES
DESCRIPTION
NAIC Company Code:
Claims Payment Period:
OCS Contract Name:
Member Months (Incurred Period):
$
Flat Copay Level
Product Name:
Earned Premium:
%
Coinsurance Level
Product Type (PPO, POS, HMO):
Gross (Allowed) Claims (before Cost‐Sharing):
Product Effective Date:
Net Paid Claims (after Member Cost‐Sharing):
Termination or Change Date:
Member Cost‐Share (Gross less Net):
Y
Yes
N
No
Member
Standard
Preferred
Preferred
Rule for Mandatory Generics:
Cost‐Share
Copay /
Facility
Facility
Step Therapy Rule:
$ or %
Coins
Y or N
Copay
Prescription Drug Formulary:
OFFICE VISITS
OTC Coverage:
If so, OTC Copay:
Flat Copay
Copay Only
Generalist Copay:
$
Pure Coins
Coinsurance Only
Specialist Copay:
$
Rx Benefit Phase I
FROM:
$0
TO:
$0
Coins w Min Copay
Coinsurance with a Minimum Copay Amount
Sub‐Specialist Copay:
$
Coins w Min & Max
Coinsurance with Minimum and Maximum Copay Amounts
Chiropractic (first visit):
$
Individual
Family
Chiropractic Manipulation:
$
Per Individual Front‐End Deductible & Max Deductible per Family:
Physical Therapy:
$
Out‐of‐Pocket Maximum (Y or N):
OOP Amounts:
Respiratory Therapy:
$
No Benefit Limit
No Dental Limit
Type of Rx
%
Min
Max
General Annual Limit
Overall Benefit Limit per Year
HOSPITAL / ASC FACILITY
Cost‐Share
Coins
Copay
Copay
Category Annual Limit
Benefit Limit per Dental Category per Year
Full Hospital Admission:
$
$0.00
GENERIC DRUGS
Category Lifetime Limit
Benefit Limit per Dental Category per Lifetime
Partial Hospital Admission:
$
$0.00
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
Ambulatory Surgical Center (ASC):
$
$0.00
Preferred Generic:
Flat Copay
0%
$0
$0
EMERGENCY VISITS
MULTI‐SOURCE BRAND DRUGS
PPO
Preferred Provider Organization (Free Access)
Accident / Trauma
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
POS
Point of Service Plan (PPO/HMO Hybrid)
w/o Nurse Triage Line:
$
$0.00
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
HMO
Health Mainenance Organization (Managed Care with Gatekeeper)
with Nurse Triage Line:
$
$0.00
Other
Other health care delivery system
Sickness & Other Urgency
SINGLE‐SOURCE BRAND DRUGS
w/o Nurse Triage Line:
$
$0.00
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$100
with Nurse Triage Line:
$
$0.00
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$100
Specialty/Biotechnological:
Coins w Min & Max
0%
$0
Generics Not Mandatory
Generic Dispense is Optional to the Member
DIAGNOSTIC
Dispense As Written (D.A.W.)
Physician May Indicate 'Do Not Substitute' w/o Penalty to Member
Standard Laboratory:
%
0%
Rx Benefit Phase II
FROM:
TO:
$ Penalty + Generic Copay
Member Pays Difference in Cost (btwn Gen & Brand) plus Generic Copay
X‐Ray:
%
0%
$ Penalty + Brand Copay
Member Pays Difference in Cost (btwn Gen & Brand) plus Brand Copay
MRI:
%
0%
Type of Rx
%
Min
Max
CT Scan:
%
0%
Cost‐Share
Coins
Copay
Copay
PET Scan:
%
0%
GENERIC DRUGS
PET/CT:
%
0%
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
No Rx Formulary
No Prescription Drug Formulary Applies to this Plan
Endoscopic:
%
0%
Preferred Generic:
Flat Copay
0%
$0
$0
Formulary Applies
Prescription Drug Formulary Applies to this Plan
SURGICAL (PROFESSIONAL)
MULTI‐SOURCE BRAND DRUGS
Hospital Setting:
%
0%
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
ASC Setting:
%
0%
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
No Step Therapy Rule
Step Therapy Not Required
Office Setting:
%
0%
Step Therapy w Waiver
Step Therapy Waived if Utilization Documented in the Last Six (6) Months
SINGLE‐SOURCE BRAND DRUGS
$ Penalty + Gen Copay
No Exceptions to Step Therapy Rule
Does this plan include Major Medical or other Supplemental Coverage?
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
If Yes, does the coverage include services rendered in the U.S.?
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
If U.S. services are covered, is pre‐authorization required?
Specialty/Biotechnological:
Coins w Min Copay
0%
$0
$0
Applicable Member Coinsurance:
Rx Benefit Phase III
FROM:
$0
TO:
$0
Individual
Family
Per Individual Front‐End Deductible & Max Deductible per Family:
Type of Rx
%
Min
Max
Out‐of‐Pocket Maximum (Y or N):
OOP Amounts:
Cost‐Share
Coins
Copay
Copay
GENERIC DRUGS
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
Preferred Generic:
Flat Copay
0%
$0
$0
MULTI‐SOURCE BRAND DRUGS
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
SINGLE‐SOURCE BRAND DRUGS
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
Specialty/Biotechnological:
Coins w Min Copay
0%
$0
$0
List of Optional Benefits Included in the Premium
No Rx Formulary
Generics Not Mandatory
No Step Therapy Rule
Prescription Drug Coverage
General Info
Experience
Medical Coverage
Major Medical
Attachment 4
Benefits Map
UNIFORM PLAN DESIGN TEMPLATE
Drop‐Down Menu Items
Carrier Name:
Incurred Experience Period:
VALUES
DESCRIPTION
NAIC Company Code:
Claims Payment Period:
OCS Contract Name:
Member Months (Incurred Period):
$
Flat Copay Level
Product Name:
Earned Premium:
%
Coinsurance Level
Product Type (PPO, POS, HMO):
Gross (Allowed) Claims (before Cost‐Sharing):
Product Effective Date:
Net Paid Claims (after Member Cost‐Sharing):
Termination or Change Date:
Member Cost‐Share (Gross less Net):
Y
Yes
N
No
Member
Standard
Preferred
Preferred
Rule for Mandatory Generics:
Cost‐Share
Copay /
Facility
Facility
Step Therapy Rule:
$ or %
Coins
Y or N
Copay
Prescription Drug Formulary:
OFFICE VISITS
OTC Coverage:
If so, OTC Copay:
Flat Copay
Copay Only
Generalist Copay:
$
Pure Coins
Coinsurance Only
Specialist Copay:
$
Rx Benefit Phase I
FROM:
$0
TO:
$0
Coins w Min Copay
Coinsurance with a Minimum Copay Amount
Sub‐Specialist Copay:
$
Coins w Min & Max
Coinsurance with Minimum and Maximum Copay Amounts
Chiropractic (first visit):
$
Individual
Family
Chiropractic Manipulation:
$
Per Individual Front‐End Deductible & Max Deductible per Family:
Physical Therapy:
$
Out‐of‐Pocket Maximum (Y or N):
OOP Amounts:
Respiratory Therapy:
$
No Benefit Limit
No Dental Limit
Type of Rx
%
Min
Max
General Annual Limit
Overall Benefit Limit per Year
HOSPITAL / ASC FACILITY
Cost‐Share
Coins
Copay
Copay
Category Annual Limit
Benefit Limit per Dental Category per Year
Full Hospital Admission:
$
$20.00
GENERIC DRUGS
Category Lifetime Limit
Benefit Limit per Dental Category per Lifetime
Partial Hospital Admission:
$
$20.00
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
Ambulatory Surgical Center (ASC):
$
$20.00
Preferred Generic:
Flat Copay
0%
$0
$0
EMERGENCY VISITS
MULTI‐SOURCE BRAND DRUGS
PPO
Preferred Provider Organization (Free Access)
Accident / Trauma
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
POS
Point of Service Plan (PPO/HMO Hybrid)
w/o Nurse Triage Line:
$
$0.00
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
HMO
Health Mainenance Organization (Managed Care with Gatekeeper)
with Nurse Triage Line:
$
$0.00
Other
Other health care delivery system
Sickness & Other Urgency
SINGLE‐SOURCE BRAND DRUGS
w/o Nurse Triage Line:
$
$0.00
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$100
with Nurse Triage Line:
$
$0.00
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$100
Specialty/Biotechnological:
Coins w Min & Max
0%
$0
Generics Not Mandatory
Generic Dispense is Optional to the Member
DIAGNOSTIC
Dispense As Written (D.A.W.)
Physician May Indicate 'Do Not Substitute' w/o Penalty to Member
Standard Laboratory:
%
10%
Rx Benefit Phase II
FROM:
TO:
$ Penalty + Generic Copay
Member Pays Difference in Cost (btwn Gen & Brand) plus Generic Copay
X‐Ray:
%
10%
$ Penalty + Brand Copay
Member Pays Difference in Cost (btwn Gen & Brand) plus Brand Copay
MRI:
%
10%
Type of Rx
%
Min
Max
CT Scan:
%
10%
Cost‐Share
Coins
Copay
Copay
PET Scan:
%
10%
GENERIC DRUGS
PET/CT:
%
10%
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
No Rx Formulary
No Prescription Drug Formulary Applies to this Plan
Endoscopic:
%
10%
Preferred Generic:
Flat Copay
0%
$0
$0
Formulary Applies
Prescription Drug Formulary Applies to this Plan
SURGICAL (PROFESSIONAL)
MULTI‐SOURCE BRAND DRUGS
Hospital Setting:
%
0%
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
ASC Setting:
%
0%
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
No Step Therapy Rule
Step Therapy Not Required
Office Setting:
%
0%
Step Therapy w Waiver
Step Therapy Waived if Utilization Documented in the Last Six (6) Months
SINGLE‐SOURCE BRAND DRUGS
$ Penalty + Gen Copay
No Exceptions to Step Therapy Rule
Does this plan include Major Medical or other Supplemental Coverage?
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
If Yes, does the coverage include services rendered in the U.S.?
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
If U.S. services are covered, is pre‐authorization required?
Specialty/Biotechnological:
Coins w Min Copay
0%
$0
$0
Applicable Member Coinsurance:
Rx Benefit Phase III
FROM:
$0
TO:
$0
Individual
Family
Per Individual Front‐End Deductible & Max Deductible per Family:
Type of Rx
%
Min
Max
Out‐of‐Pocket Maximum (Y or N):
OOP Amounts:
Cost‐Share
Coins
Copay
Copay
GENERIC DRUGS
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
Preferred Generic:
Flat Copay
0%
$0
$0
MULTI‐SOURCE BRAND DRUGS
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
SINGLE‐SOURCE BRAND DRUGS
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
Specialty/Biotechnological:
Coins w Min Copay
0%
$0
$0
Generics Not Mandatory
No Step Therapy Rule
No Rx Formulary
Major Medical
Medical Coverage
Prescription Drug Coverage
List of Optional Benefits Included in the Premium
General Info
Experience
Attachment 4
Benefits Map
UNIFORM PLAN DESIGN TEMPLATE
Drop‐Down Menu Items
Carrier Name:
Incurred Experience Period:
VALUES
DESCRIPTION
NAIC Company Code:
Claims Payment Period:
OCS Contract Name:
Member Months (Incurred Period):
$
Flat Copay Level
Product Name:
Earned Premium:
%
Coinsurance Level
Product Type (PPO, POS, HMO):
Gross (Allowed) Claims (before Cost‐Sharing):
Product Effective Date:
Net Paid Claims (after Member Cost‐Sharing):
Termination or Change Date:
Member Cost‐Share (Gross less Net):
Y
Yes
N
No
Member
Standard
Preferred
Preferred
Rule for Mandatory Generics:
Cost‐Share
Copay /
Facility
Facility
Step Therapy Rule:
$ or %
Coins
Y or N
Copay
Prescription Drug Formulary:
OFFICE VISITS
OTC Coverage:
If so, OTC Copay:
Flat Copay
Copay Only
Generalist Copay:
$
Pure Coins
Coinsurance Only
Specialist Copay:
$
Rx Benefit Phase I
FROM:
$0
TO:
$0
Coins w Min Copay
Coinsurance with a Minimum Copay Amount
Sub‐Specialist Copay:
$
Coins w Min & Max
Coinsurance with Minimum and Maximum Copay Amounts
Chiropractic (first visit):
$
Individual
Family
Chiropractic Manipulation:
$
Per Individual Front‐End Deductible & Max Deductible per Family:
Physical Therapy:
$
Out‐of‐Pocket Maximum (Y or N):
OOP Amounts:
Respiratory Therapy:
$
No Benefit Limit
No Dental Limit
Type of Rx
%
Min
Max
General Annual Limit
Overall Benefit Limit per Year
HOSPITAL / ASC FACILITY
Cost‐Share
Coins
Copay
Copay
Category Annual Limit
Benefit Limit per Dental Category per Year
Full Hospital Admission:
$
$20.00
GENERIC DRUGS
Category Lifetime Limit
Benefit Limit per Dental Category per Lifetime
Partial Hospital Admission:
$
$20.00
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
Ambulatory Surgical Center (ASC):
$
$20.00
Preferred Generic:
Flat Copay
0%
$0
$0
EMERGENCY VISITS
MULTI‐SOURCE BRAND DRUGS
PPO
Preferred Provider Organization (Free Access)
Accident / Trauma
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
POS
Point of Service Plan (PPO/HMO Hybrid)
w/o Nurse Triage Line:
$
$0.00
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
HMO
Health Mainenance Organization (Managed Care with Gatekeeper)
with Nurse Triage Line:
$
$0.00
Other
Other health care delivery system
Sickness & Other Urgency
SINGLE‐SOURCE BRAND DRUGS
w/o Nurse Triage Line:
$
$0.00
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$100
with Nurse Triage Line:
$
$0.00
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$100
Specialty/Biotechnological:
Coins w Min & Max
0%
$0
Generics Not Mandatory
Generic Dispense is Optional to the Member
DIAGNOSTIC
Dispense As Written (D.A.W.)
Physician May Indicate 'Do Not Substitute' w/o Penalty to Member
Standard Laboratory:
%
10%
Rx Benefit Phase II
FROM:
TO:
$ Penalty + Generic Copay
Member Pays Difference in Cost (btwn Gen & Brand) plus Generic Copay
X‐Ray:
%
10%
$ Penalty + Brand Copay
Member Pays Difference in Cost (btwn Gen & Brand) plus Brand Copay
MRI:
%
10%
Type of Rx
%
Min
Max
CT Scan:
%
10%
Cost‐Share
Coins
Copay
Copay
PET Scan:
%
10%
GENERIC DRUGS
PET/CT:
%
10%
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
No Rx Formulary
No Prescription Drug Formulary Applies to this Plan
Endoscopic:
%
10%
Preferred Generic:
Flat Copay
0%
$0
$0
Formulary Applies
Prescription Drug Formulary Applies to this Plan
SURGICAL (PROFESSIONAL)
MULTI‐SOURCE BRAND DRUGS
Hospital Setting:
%
0%
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
ASC Setting:
%
0%
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
No Step Therapy Rule
Step Therapy Not Required
Office Setting:
%
0%
Step Therapy w Waiver
Step Therapy Waived if Utilization Documented in the Last Six (6) Months
SINGLE‐SOURCE BRAND DRUGS
$ Penalty + Gen Copay
No Exceptions to Step Therapy Rule
Does this plan include Major Medical or other Supplemental Coverage?
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
If Yes, does the coverage include services rendered in the U.S.?
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
If U.S. services are covered, is pre‐authorization required?
Specialty/Biotechnological:
Coins w Min Copay
0%
$0
$0
Applicable Member Coinsurance:
Rx Benefit Phase III
FROM:
$0
TO:
$0
Individual
Family
Per Individual Front‐End Deductible & Max Deductible per Family:
Type of Rx
%
Min
Max
Out‐of‐Pocket Maximum (Y or N):
OOP Amounts:
Cost‐Share
Coins
Copay
Copay
GENERIC DRUGS
Non‐Preferred Generic:
Flat Copay
0%
$0
$0
Preferred Generic:
Flat Copay
0%
$0
$0
MULTI‐SOURCE BRAND DRUGS
Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
Non‐Preferred Multi‐Source Brand:
Coins w Min & Max
0%
$0
$0
SINGLE‐SOURCE BRAND DRUGS
Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
Non‐Preferred Single‐Source Brand:
Coins w Min Copay
0%
$0
$0
Specialty/Biotechnological:
Coins w Min Copay
0%
$0
$0
Generics Not Mandatory
No Step Therapy Rule
No Rx Formulary
Major Medical
Medical Coverage
Prescription Drug Coverage
List of Optional Benefits Included in the Premium
General Info
Experience
Attachment 4
Plan Cost Summary (All Plan Designs Combined)
DETAIL OF NET COST AND MEMBER COST‐SHARE BY SERVICE CATEGORY
Carrier Name:
NAIC Company Code:
Net
Cost
Total
Net
Cost
Total
Net Paid
Member
Total
Member
Service
% Net
% Cost
Claims
Share
Cost
Claims
Share
Cost
Claims
Cost‐Share
Gross Cost
Months
Count
Claims
Share
PMPM
PMPM
PMPM
Per Serv
Per Serv
Per Serv
Medical Coverage Experience
Generalist Office Visits
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Specialist Office Visits
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Sub‐Specialist Office Visits
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Chiropractic Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Physical Therapy
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Respiratory Therapy
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Hospital Per Diem Expense
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Other Hospital Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Ambulatory Surgical
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Emergency ‐ Accident/Trauma
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Emergency ‐ Sickness/Urgency
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Standard Laboratory
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
X‐Ray Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
MRI Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
CT Scan Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
PET Scan Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
PET/CT Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Endoscopic Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Surgery ‐ Hospital Setting
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Surgery ‐ ASC Setting
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Surgery ‐ Office Setting
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
All Other Medical Services
0%
0%
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
TOTAL MEDICAL SERVICES
‐
$
‐
$
‐
$
0%
0%
‐
$
‐
$
‐
$
Major Medical Experience
Services Rendered in PR
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Services Rendered in US
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
TOTAL MAJOR MEDICAL SERVICES
‐
$
‐
$
‐
$
Prescription Drug Experience
Generic (Pref & Non‐Pref)
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Preferred Multi‐Source Brand
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Non‐Preferred Multi‐Source Brand
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Preferred Single‐Source Brand
‐
$
‐
$
‐
$
‐
$
‐
$
Non‐Preferred Single‐Source Brand
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
Specialty/Biotechnological
‐
$
‐
$
‐
$
‐
$
‐
$
‐
$
TOTAL Rx DRUG SERVICES
‐
$
‐
$
‐
$
Attachment 5
Carrier Name:
Date of Initial Filing:
Is this Original or Replacement:
NAIC Company Code:
SERFF Tracking Number:
Market:
Item
File name and page or
worksheet
Carrier verified
complete filing
(initial)
Unified Rate Review Template (Excel and PDF)
Public Form of the Rate Filing Information to be
Placed on the OCI website (For Increases
Greater than 10% this will be the Preliminary
Justification Part II)
Brief description in simple language the reasons why the rate increase is
being requested.
Explanation of the most significant factors causing the rate increase,
including a brief description of the relevant claims and non-claims
expense increases reported in the rate increase summary
Brief description of the overall experience of the policy, including
historical and projected expenses, and loss ratios.
Actuarial Memorandum meeting the
requirements of Puerto Rico and the Federal
2014 Actuarial Memorandum and Certification
Instructions 2.0 (Part III)
General Information
Company legal name
HIOS issuer ID
Market
Effective date
Primary contact name, telephone number, email address
Overview of Rate Increase
Provide a brief explanation of why a rate increase is being requested and
on what policy forms including the names of the policy forms affected.
Describe the scope and driving factors impacting the rate increase
including a description of how the rates were determined.
Overview of products. This should be a description of type of products,
benefits, marketing method, premium classifications, renewability, and
underwriting method.
Historical rate increase for last 3 years.
Rate increase detailed information such as averages, minimum and
maximum
Effective through date and any rate increase schedule applicable (small
group only)
Include all products which are part of the single risk pool, including
those with no proposed rate adjustment
Base Period Experience
Explanation of the base period used indicating the basis of the data used,
first and last incurred date included.
Indicate paid through date
Provide support for the development of the actuary's best estimate of
allowed and paid claims incurred during the experience period
Describe the treatment of large claims and claims pooling, if any.
Treatment of commercial reinsurance, if any. This is separate from the
Transitional Federal Reinsurance program, but is adjustments for
commercial reinsurance purchased by the carrier to protect against the
risk of large claims.
Indicate the amount of MLR rebates refunded during experience period
Exhibit showing current age distribution with those anticipated for
projection period
Capitation Payments
Describe what is covered by any capitation payments.
Projection Factors
Provide documentation of all assumptions and methodologies used in the
development of the impact of morbidity and enrollee mix.
If there were changes in the benefits covered, provide a description of all
benefit changes and quantitative support of their impact.
For each Essential Health Benefit (EHB) not covered previously, the
additional cost per-member-per-month (PMPM) with an actuarial
explanation of how the additional cost was developed.
For adjustment factors related to differences in demographics, if
applicable, include a description of the source data or assumptions used,
why they are appropriate for the single risk pool, and any applicable
adjustments made to the data, such as considerations for issuer specific
experience, industry or internal studies, benefit design and credibility.
If there are other changes impacting rates, provide a description and
quantitative documentation of all factors.
Provide a description of all changes in the rating structure, if any, and
provide quantitative support of their impact including all assumptions
used.
Provide quantitative support of the impact due to changes to network, if
any.
Provide quantitative documentation of the trend development including
as well as an explanation of the data, assumptions, and periods used.
Changes in medical cost trend by major service categories for the past
three years and future projections.
Changes in the use of services by major service categories for the past
three years and future projections.
Please explain significant changes from the prior filing assumptions.
Manual Rate Development, if applicable
Describe the source data used to develop the manual rate and why such
data is appropriate.
Describe all adjustments made to the data underlying the development of
the manual rate to account for differences in demographics, benefits and
morbidity/risk to ensure that that resulting manual rate is appropriate for
blending with the adjusted experience period claims.
Credibility
Indicate the credibility methodology and credibility level of the base
period experience.
Paid to Allowed Ratio
Provide a quantitative demonstration of the development of the paid to
allowed ratio based on company specific projections.
Non-Benefit Expense Projections
Administrative Costs
The methodology used to project administrative expenses, including
gain/loss margins, should be explained.
Identify the main factors that affect changes in administrative costs.
Discuss how changes in projected administrative costs are impacting the
rate increase and what is driving these changes.
Actual administrative expenses PMPM for the last three years and
explain any changes in administrative expenses from the prior filings.
Breakdown of projected administrative expenses with any quality
improvement costs separated.
Discuss how and why the percentage administrative load varies by
product or plan, if applicable
Projected Gain/Loss Margins
Describe the target underwriting gain/loss margin, and any additional
risk margin
To the extent that the target as a percent of premium has changed from
the prior submission, provide additional support for why the change is
warranted
Discuss how the percentage load varies by product or plan, if applicable
Taxes and Fees
Describe each tax and/or fee and indicate the amount for each, either as a
percent of premium or a PMPM amount and a quantitative development.
Provide an explanation of how taxes and fees were allocated across
plans.
Medical Loss Ratio
Provide a demonstration of the projected loss ratio using the federal
rebate loss ratio formula including the values used.
Describe how the credibility adjustment was determined, if applicable.
If the projected loss ratio is less than federal requirement, explain the
plan to comply with the Federal MLR requirement.
Index Rate
Demonstrate in Excel with formulas how the projected market level
index rate was adjusted to arrive at each plan level index rate.
Provide an example procedure of determining a family rate. Demonstrate
that this family rating complies with the federal rating rules of the ACA.
For the catastrophic plan rate, describe the methodology used to estimate
the adjustment reflecting differences in anticipated demographics and
morbidity of the catastrophic population as compared to the single risk
pool
AV Metal Values
The issuer must describe whether the AV Metal Values included were
entirely based on the AV Calculator, or whether an acceptable alternative
methodology was used to generate the AV Metal Value of one or more
plans
If an alternate methodology was employed to develop the AV Metal
Value(s), the actuary must provide a copy of the actuarial certification
required by 45 CFR Part 156, §156.135
Provide all AVC screen shots
Plan-Adjusted Index Rate
Quantitative development in Excel (with working formulas) of the plan-
adjusted index rates starting with the market index rate.
Membership Projections
Describe how the membership projections were developed
Describe any differences between the distribution of projected member
months relative to the current membership distribution
Company Financial Condition
Describe the financial situation of the company, including surplus, if
any. Provide 5 years of RBC ratio levels.
Provide historic loss ratios.
Terminated Products
List the name of each product that will be terminated prior to the
effective date including other products that have experience included in
the single risk pool during the experience period and any products that
were not in effect during the experience but were made available
thereafter
Plan Type
In the event that the plan types listed in the drop-down box in Worksheet
2, Section I of the Part I Unified Rate Review Template do not describe
an issuer’s plan exactly and the issuer has selected the closest plan
available, per the instructions, please describe the differences between
the issuer’s plan and the plan type selected.
Warning Alerts
Describe any difference between the sum of the plan level projections
and the total projected amounts
Reliance
If the certifying actuary relied on any information or underlying
assumptions provided by another individual, the information relied upon
and the name of the individual providing that information may be
disclosed.
For All Small Groups Affected
Name of group
Group's average rate increase
Date of contract renewal
Effective date of rate increase
Federal Actuarial Certification
Puerto Rico Certification Letter
SERFF Rates Template (Excel)
Rating Manual (if filed previously indicate date
filed)
Puerto Rico Benefits Maps for each plan (if filed
previously indicate date filed)
Attachment 6
Benefit
Limits
Page
Primary Care Visit to Treat an Injury or Illness
No
Specialist Visit
No
Other Practitioner Office Visit (Nurse, Physician
Assistant)
Non physician professionals or doctors in odontology including nurse
and physician assistant except those required by local law such as:
podiatrist, audiologist, optometrist, clinical psychologists and
chiropractors.
Outpatient Facility Fee (e.g., Ambulatory Surgery
Center)
Services rendered in an outpatient facility that may be performed in
physician's office are not covered.
Outpatient Surgery Physician/Surgical Services
Excludes: Cosmetic surgery, oral surgery that is dental in origin
except those as a result of an accident, mammoplasty (except
those required for patients after a breast cancer mastectomy),
septoplasty, blepharoplasty, rinoseptoplasty, procedures to reestablish the ability to procreate, organ transplant procedures
(OT covered as an optional benefit), induced abortion
experimental procedures, skin tags removal, ptosis repair, nail
excisions, scalenotomy, Lasik and other surgical procedures to
correct refractive defects, surgeries for sexual transformation,
surgical assistance services, intravenous analgesia services or
analgesia administered though inhalation at the physician or
dentist's office, services for the treatment of the
temporamandibular articulation syndrome, excision of
granulomas or radicular cysts orginated by infection in the tooth
pulp; services to correct the vertical dimension or occlusion,
removal of exostosis (mandibulary or maxillary).
Routine Dental Services (Adult)
Dental checkup and cleanning 2 per policy year (every 6 months);
bitewings and periapicals no more that one set every 3 years.
Orthodontic, Periodontics, Endodontic and prosthetic dental services
are not covered. Full mouth reconstructions. (covered as an optional
coverage) Fluoride treatment covered to members under age 19. Root
canal only to anterior and posterior teeth.
Routine Eye Exam (Adult)
Refraction exam is covered one per year, per member
Urgent Care Centers or Facilities
No
Essential Health Benefits and Preventevise Services Checklist
Essential Health Benefits
1
Benefit
Limits
Page
Home Health Care Services
Combined limit. Limit applies to physical, occupational and speech
therapy. Covered only if they begin 14 days after member;s discharge
from hospital of at least three (3) days and if they are provided for the
same condition by he/she was admitted.
Emergency Room Services
No
Emergency Transportation/Ambulance
Covered by reimbursement up to $80 per trip
Inpatient Hospital Services (e.g., Hospital Stay)
Excludes services for personal comfort and or custodial services.
Hospitalizations for services or procedures that may be performed in
an outpatient services.
Inpatient Physician and Surgical Services
No
Bariatric Surgery
Subject to preauthorization, it must be covered the payment of one of
the types of the bariatric surgery for life in Puerto Rico, if the services
are available. The types of bariatric surgery that must be covered are
the following: gastric bypass, adjustable band or sleeve gastrectomy.
Skilled Nursing Facility
Covered only if they begin 14 days after member's discharge from
hospital of at least three (3) days and if they are provided for the same
condition by he/she was admitted.
Prenatal and Postnatal Care
Covered only for mainholder and dependent spouse.
Delivery and All Inpatiente Services for Maternity
Care
Delivery of baby 48 hour minimum length for vaginal delivery and 96
for cesarean delivery. Covered only for main holder and dependent
spouse.
Mental/Behavioral Health Outpatient Services
No limit in accordance to the Mental Health Parity Act.
Mental/Behavioral Health Inpatient Services
Residential treatment outside service area is not covered. No limit in
accordance to the Mental Health Parity Act. Expenses for services
resulting from the administration of an employer drug detection
program not covered.
Substance Abuse Disorder Outpatient Services
No limit in accordance to the Mental Health Parity Act. Expenses for
services resulting from the administration of an employer drug
detection program not covered.
2
Benefit
Limits
Page
Substance Abuse Disorder Inpatient Services
No limit in accordance to the Mental Health Parity Act. Partials are
included: 2 partial hospital days equivalent to 1 regular day.
Residential treatment outside service area is not covered.
Generic Drugs
Subject to a Drug List, Generics as a first option, Some medications
require precertification, Step therapy applies for some drugs.
Preferred Brand Drugs
Subject to a Drug List, Generics as a first option, Some medications
require precertification, Step therapy applies for some drugs.
Non-Preferred Brand Drugs
Subject to a Drug List, Generics as a first option, Some medications
require precertification, Step therapy applies for some drugs.
Specialty Drugs
Subject to a Drug List, Generics as a first option, Some medications
require precertification, Step therapy applies for some drugs.
Outpatient Rehabilitation Services
20 Physical therapies or manipulations covered under a combined
limit per policy year per member. Services not covered include
occupational, speech and language therapies, prosthetics and
implants. Orthopedics and orthotic devices, cardic rehabilitation.
Services limited to physical therapies, except for those covered under
home health care benefit.
Habilitation Services
20 Physical therapies or manipulations covered under a combined
limit per year. Services limited to physical therapies, except for those
covered under home health care benefit.
Chiropractic Care
20 Physical therapies or manipulations covered under a combined
limit per policy year per member.
3
Benefit
Limits
Page
Durable Medical Equipment
Covers with a preauthorization from plan rental or purchase or Oxygen
and necessary equipment for its administration/wheelchair/hospital
bed. Mechanical respirators and ventilators are covered without limits
as required by local law to member's patients under age of 21.
Diagnostic Test (X-Ray and Lab Work)
No
Imaring (CT/PET Scans, MRIs)
1 Per policy year per member for Pet & PET/CT, per anatomical
region per year for MRI & CT
Preventive Care/Screening/Immunization
Preventive care that meets recommendations described in ACA
Routine Foot Care
No
Routine Eye Exam for Children
1 Visit per year supplemented using FEDVIP.
Eye Glasses for Children
1 pair of glasses (lenses and frames per year). Supplemented using
FEDVIP
Dental Check-Up for Children
Dental checkup and cleanings 2 per policy year per member (every 6
months); bitewings and periapicals no more than one set every 3
years. Covered under the dental benefit which is offered as an optional
benefit.
Allergy tests
50 Test per policy year. Vaccines not covered.
Dialysis and hemodialysis
90 Days. Services related to any type of dialysis or hemodialysis, as
well as services for any complication that may arise and their
corresponding hospital or medical-surgical services, will be covered
for the first 90 days form: a) the date in which the member became
eligible for the policy during the first time or, b) the date in which
he/she received the first dialysis and hemodialysis. This will apply
when subsequent dialysis or hemodialysis are related to the same
clinical conditions.
Injectable chemotherapy
No
Radiation therapy
No
Intra-articular injections
12 Inyections per policy year per member, up to 2 daily injections
Cryo-surgery of the uterus
1 procedures per year
Sterilization
No
Invasive cardiovascular, non-invasive cardiovascular
procedures and tests
Electromiograms covered up to 2 procedures per year
4
Benefit
Limits
Page
Nuclear medicine tests
No
Nerve conduction velocity tests
2 Procedures per policy year
Gastrointestinal endoscopies
No
Polysomnography
1 Type of test per lifetime
Tympanometry
1 Per policy year
Nutritionist services
4 Per policy year. Limited to morbid, renal and diabetes conditions.
Covered by reimbursement up to $20 per visit
Transplant Services
Medical benefit covers skin, bone and corneal transplants.
Orthognatic surgery
Expenses related for materials are excluded.
Lithotripsy
No
Air ambulance
No. Out of area air ambulance coverage is not covered.
Out of area coverage (US)
Services are covered for emergency cases or cases that required
equipment, treatment and facilities not available in Puerto Rico.
Services are subject to preautorization from plan except for an
emergency. Elective treatments, not considered as an emergency, are
not covered by this policy.
Biophysical profile
1 Procedures per pregnancy
MRA
No
Contraceptive methods
No
Neurological tests and procedures
No
All Puerto Rico mandated benefits
No
Benefit
Limits
Page
Abdominal Aortic Aneurysm
One-time screening for abdominal aortic aneurysm (AAA) by
ultrasonography in men aged 65 to 75 who have ever smoked.
Alcohol Misuse
Screening and counseling. The USPSTF recommends that clinicians
screen adults aged 18 years or older for alcohol misuse and provide
persons engaged in risky or hazardous drinking with brief behavioral
counseling interventions to reduce alcohol misuse.
Aspirin
Use for men ages 45 to 79 years and for women ages 55 to 79 years
when the potential benefit due to a reduction in myocardial infarctions
outweighs the potential harm due to an increase in gastrointestinal
hemorrhage.
Blood Pressure
Screening for high blood pressure in adults age 18 years and older
Individual
Covered Preventive Services for Adult
5
Benefit
Limits
Page
Cholesterol
Screening men aged 20 to 35 for lipid disorders if they are at
increased risk for coronary heart disease. The U.S. Preventive
Services Task Force (USPSTF) strongly recommends screening men
aged 35 and older for lipid disorders. The USPSTF strongly
recommends screening women aged 45 and older for lipid disorders if
they are at increased risk for coronary heart disease. The USPSTF
recommends screening women aged 20 to 45 for lipid disorders if they
are at increased risk for coronary heart disease.
Colorectal Cancer
The USPSTF recommends screening for colorectal cancer (CRC)
using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in
adults, beginning at age 50 years and continuing until age 75 years.
The risks and benefits of these screening methods vary.
Depression
Screening for adults
Type 2 Diabetes
Screening for type 2 diabetes in asymptomatic adults with sustained
blood pressure (either treated or untreated) greater than 135/80 mm
Hg.
Diet
The USPSTF recommends intensive behavioral dietary counseling for
adult patients with hyperlipidemia and other known risk factors for
cardiovascular and diet-related chronic disease. Intensive counseling
can be delivered by primary care clinicians or by referral to other
specialists, such as nutritionists or dietitians.
HIV
Clinicians screen for HIV infection in adolescents and adults ages 15
to 65 years. Younger adolescents and older adults who are at
increased risk should also be screened. Recommends that clinicians
screen all pregnant women for HIV, including those who present in
labor who are untested and whose HIV status is unknown.
Immunization
Vaccines for adults-doses, recommended ages, and recommended
populations vary: Hepatitis A, Hepatitis B, Herpes Zoster, Human
Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella,
Meningococcal, Pneumococcal, Tetanus, Diphteria, Pertussin,
Varicella
Obesity
The USPSTF recommends screening all adults for obesity. Clinicians
should offer or refer patients with a body mass index of 30 kg/m2 or
higher to intensive, multicomponent behavioral interventions.
6
Benefit
Limits
Page
Sexually Transmitted Infection (STI)
The USPSTF recommends high-intensity behavioral counseling to
prevent sexually transmitted infections (STIs) for all sexually active
adolescents and for adults at increased risk for STIs.
The USPSTF recommends high-intensity behavioral counseling to
prevent sexually transmitted infections (STIs) for all sexually active
adolescents and for adults at increased risk for STIs.
Tobacco Use
The USPSTF recommends that clinicians ask all adults, about tobacco
use and provide tobacco cessation interventions for those who use
tobacco products.
Syphilis
Screening for all adults at higher risk
Benefit
Limits
Page
Anemia
Routine screening for iron deficiency anemia in asymptomatic
pregnant women.
Bacteriuria
screening for asymptomatic bacteriuria with urine culture for pregnant
women at 12 to 16 weeks' gestation or at the first prenatal visit, if later.
BRCA
The USPSTF recommends that primary care providers screen women
who have family members with breast, ovarian, tubal, or peritoneal
cancer with one of several screening tools designed to identify a family
history that may be associated with an increased risk for potentially
harmful mutations in breast cancer susceptibility genes (BRCA1 or
BRCA2). Women with positive screeing results should receive genetic
counseling and, if indicated after counseling, BRCA testing.
Breast Cancer Mammography
Screening every 1 to 2 years for women over 40. The USPSTF
recommends biennial screening mammography for women aged 50 to
74 years.
Brest Cancer Chemoprevention
Counseling for women at higher risk
Breastfeeding
Comprehensive lactation support and counseling, by a trained provider
during pregnancy and/or in the postpartum period, and costs access to
breastfeading equipment and supplies. In conjunction with each birth.
Cervical Cancer
Screening for sexaully active women. The USPSTF recommends
screening for cervical cancer in women ages 21 to 65 years with
cytology (Pap smear) every 3 years or, for women ages 30 to 65 years
who want to lengthen the screening interval, screening with a
combination of cytology and human papillomavirus (HPV) testing
every 5 years
Covered Preventive Services for Women, Including Pregnant
7
Benefit
Limits
Page
Chlamydia Infection
Screening for chlamydial infection in all pregnant women ages 24 and
younger and in older pregnant women who are at increased risk.
Screening for chlamydial infection in all sexually active, nonpregnant
young women ages 24 and younger and in older nonpregnant women
who are at increased risk.
Contraception
All Food and Drug Administration approved contraceptive methods,
sterilization procedures, and patient education and counseling for all
women with reproductive capacity. As prescribed.
Domestic and interpersonal violence
Screening and counseling for interpersonal and domestic violence.
Folic Acid
The USPSTF recommends that all women planning or capable of
pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to
800pg) of folic acid.
Gestational diabetes
Screening for gestational diabetes. In pregnant women between 24
and 28 weeks of gestation and at the first prenatal visit for pregnant
women identified to be at high risk for diabetes.
Gonorrhea
The USPSTF recommends that clinicians screen all sexually active
women, including those who are pregnant, for gonorrhea infection if
they are at increased risk for infection (that is, if they are young or
have other individual or population risk factors).
Hepatitis B
Screening for pregnant women at their first prenatal visit
Human Immunodeficiency Virus (HIV)
Clinicians should screen all pregnant women for HIV, including those
who present in labor who are untested and whose HIV status is
unknown.
Humana Papillomavirus (HPV) DNA Test
High-risk human papillomavirus DNA testing in women with normal
cytology results. Screening should begin at 30 years of age and should
occur no more frequently than every 3 years.
Osteoporosis
Screening for osteoporosis in women age 65 years and older and in
younger women whose fracture risk is equal to or greater than that of
a 65-year-old white woman who has no additional risk factors.
RH Incompatibility
Rh (D) blood typing and antibody testing for all pregnant women during
their first visit for pregnancy-related care. Also, the USPSTF
recommends repeated Rh (D) antibody testing for all unsensitized Rh
(D)-negative women at 24-28 weeks' gestation, unless the biological
father is known to be Rh (D)-negative.
8
Benefit
Limits
Page
Tobacco Use
The USPSTF recommends that clinicians ask all pregnant women
about tobacco use and provide augmented, pregnancy-tailored
counseling to those who smoke.
Sexually Transmitted Infections (STI)
Counseling on sexually transmitted infections for all sexually active
women.
Syphilis
Screening for all pregnant women or other women at increased risk.
The U.S. Preventive Services Task Force (USPSTF) strongly
recommends that clinicians screen persons at increased risk for
syphilis infection.
Well-woman visits
Well-woman preventive care visit annually for adult women to obtain
the recommended preventive services that are age and
developmentally appropriate, including preconception care and many
services necessary for prenatal care. This well-woman visit should,
where appropriate, include other preventive services listed in this set
of guidelines, as well as others referenced in section 2713. Annual,
although HHS recognizes that several visits may be needed to obtain
all necessary recommended preventive services, depending on a
woman’s health status, health needs, and other risk factors
Benefit
Limits
Page
Alcohol and Drug Use
Assessment for adolescents
Autism
Screening for children at 12 and 36 months
Behavioral
assessment for children of all ages. Ages: 0 to11 months, 1 to 4 years,
5 to 10 years, 11 to 14 years, 15 to 17 years
Blood Pressure
The USPSTF recommends screening for high blood pressure in adults
age 18 years and older.
Cervical Dysplasia
Screening for sexually active females
Congenital Hypothyroidism
Screening for newborns
Depression
The USPSTF recommends screening adolescents (ages 12-18 years)
for major depressive disorder when systems are in place to ensure
accurate diagnosis, psychotherapy (cognitive-behavioral or
interpersonal), and follow-up.
Developmental
Screening for children under age 3, and surveillance throughout
childhood
Dyslipidemia
Screening for children at higher risk of lipid disorders. Ages: 1 to 4
years, 5 to 10 years, 11 to 14 years, 15 to 17 years
Fluoride Chemoprevention
Supplements for children without fluoride in their water source
Gonorrhea
preventive medication for the eyes of all newborns
Hearing
Screening for all newborns
Covered Preventive Services for Children
9
Benefit
Limits
Page
Height, Weight and Body Mass Index
Measurements for children. Ages: 0 to 11 months, 1 to 4 years, 5 to 10
years, 11 to 14 years, 15 to 17 years
Hemotocrit or Hemoglobin
Screening for children
Hemoglobinophathies
or sickle cell screening for newborns
HIV
The USPSTF recommends that clinicians screen for HiV infection in
adolescents and adults ages 15 to 65 years. Younger adolescents and
older adults who are at increased risk should also be screened.
Immunization
Vaccines for children from bith to age 18 - doses, recommended ages,
and recommended populations vary: Diphtheria, Tetanus, Pertussis,
Haemophilus inluenzae type b, Hepatitis A, Hepatitis B, Human
Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles,
Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus, Varicella
Iron
Supplements for children ages 6 to 12 months at risk for anemia
Lead
This USPSTF recommendation addresses screening for elevated
blood lead levels in children aged 1 to 5 years who are both at average
and increased risk, and in asymptomatic pregnant women.
Medical History
for all children throughout development Ages: 0 to 11 months, 1 to 4
years, 5 to 10 years
Obesity
The USPSTF recommends that clinicians screen children age 6 years
and older for obesity and offer them or refer them to comprehensive,
intensive behavioral interventions to promote improvement in weight
status.
Oral Health
risk assessment for young children. Ages: 0 to 11 months, 1 to 4
years, 5 to 10 years.
Phenylketonuria (PKU)
Screening for this genetic disorder in newborns
Sexually Transmitted Infection (STI)
The USPSTF recommends high-intensity behavioral counseling to
prevent sexually transmitted infections (STIs) for all sexually active
adolescents at increased risk for STIs.
Tuberculin
testing for children at higher risk of tuberculosis. Ages: 0to 11 months,
1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
Vision
The USPSTF recommends vision screening for all children at least
once between the ages of 3 and 5 years, to detect the presence of
amblyopia or its risk factors.
Skin Cancer behavioral counseling
The USPSTF recommends counseling children, adolescents, and
young adults aged 10 to 24 years who have fair skin about minimizing
their exposure to ultraviolet radiation to reduce risk for skin cancer.
10
COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
GENERAL REQUIREMENTS
Attachment 7
COMPANY: _________________________________________________________
FORM NUMBER: _________________________________________________________
REQUIREMENTS
Reference /Page/
Paragraph
Section 3(A)(1)
Every filing shall be accompanied with a transmittal Letter including the name of the insurer or health
services organization making the filing under the signature of an authorized person.
Section 3(A)(2)
If it is a new form, the transmittal letter should so indicate, in addition to offering a description of the
coverage and the form.
Section 3(A)(3)
If it is a revision of a form previously submitted, it should be so indicated in the transmittal letter, adding
also the date of approval of the old form and listing the changes.
Section 3(A)(4)
The transmittal letter should list all of the forms that are included, their respective titles and form numbers.
The transmittal letter should indicate the SERFF tracking number of the Rate filing where the rates
applicable to the product were submitted.
Chapter 11
Insurance Code of PR
§ 1107
Application required for insurance.
Chapter 27
Insurance Code of PR
§ 2725
The application must include the prescribed fraud warning statement.
Medical/ Lifestyle questions that should be taken into consideration in life and health applications. Any
question of past or present health of any person that refers to a specific disease or general health must be
asked “to the best of the applicant’s knowledge and belief”.
Any issuer may require an applicant for group or individual health plan to fill out a medical questionnaire
whereby information about preexisting conditions, as well as current prescriptions taken and care received
to control a health condition, and the information of the primary care provider treating such condition. The
information provided in such questionnaire shall be used solely and exclusively by the issuer for the
purpose of registering the enrollee in an established program to manage diseases.”
Chapter 14
Health Insurance Code of PR
§ 14.100
A health insurance organization or issuer shall not collect, use or disclose protected health information
without a valid authorization from the subject of the protected health information, except as permitted by
Section 14.110 of this Code or as required by law or court order. An authorization for the disclosure of
protected health information may be obtained for any purpose, provided that the authorization meets the
requirements of this Section.
Every policy to be effective in Puerto Rico shall be offered in the Spanish language and shall be issued in
the English language at the option of the proposed insured. In the interpretation of said policies, the text
that is of most benefit to the insured shall prevail. The provisions of this subsection shall not apply to such
insurance which the Commissioner, through regulations to that effect, may exclude because of its
technical nature or volume.
The filing shall include the table with copayments, coinsurance and deductibles in the required format.
REGULATION
Rule XXIV of the Regulations
of the
Insurance Code of PR
ADDITIONAL REQUIREMENTS
APPLICATION FORM
Ruling Letter No. N-AV-I-8-38-90 of
August 14, 1990
and
Section 10.150(F) of the
Health Insurance Code
Chapter 11
Insurance Code of PR
§ 1114(2)
As used in the entire checklist the terms insurance, insurer, insured and policy means for HMO's coverage, organization, subscriber and contract, respectivelly.
1
OCI Rev. March 2014
REQUIREMENTS
Reference /Page/
Paragraph
REGULATION
The filing shall include the formulary (list of prescription drugs) by therapeutic category; Information
indicating which prescription drugs, if any, are subject to a management procedure that has been
developed and maintained pursuant to this Chapter; and Information on how and what written
documentation is required to be submitted in order for covered persons or enrollees, or their authorized
representatives, to file a request under the health insurance organization or issuer ’s medical exceptions
process established pursuant to Section 4.070 of this Chapter.
The filing shall include the providers directory.
A certification must be included establishing that the language included in the policy/contract related to the
Federal Laws ERISA and COBRA complies in its entirety with the dispositions established in the
mentioned federal laws. Moreover, the language included in the policy/contract does not contain any
additional limitations, conditions or contrary language.
As a requirement, the below certification must be completed, signed and included with the filing.
The transmittal letter should be attached in the “Supporting Documentation Tab”.
Any supporting documentation should be included in the “Supporting Documentation Tab”, including
evidences of previous approval, the table with copayments, coinsurance and deductibles, certifications,
memorandum of variable material, among others.
All forms to be approved shall be included in the “Form Schedule Tab”
Forms and documents must be saved in a non-protected PDF format so that the file remains searchable
and text can be copied from the document.
Every communication should be included in SERFF as a “Note to Reviewer” or a “Response Letter”. Any
other way of communication will not be considered as received.
CERTIFICATION
I ____________________________________have reviewed or supervised the preparation of the above
form(s) and certify that the same comply with all of the applicable requirements of the Puerto Rico Form
Filing Check List and that the filing does not contain dispositions previously disapproved or required to be
corrected by the Office of the Commissioner of Insurance of Puerto Rico.
I also acknowledge
responsibility for the validity, accuracy and completeness of the contents of the transmittal letter and
enclosures with this filing.
Signature:__________________________________________________________________
Date: _____________________________________________________________________
Instructions to Submit the filing on SERFF
Circular Letter No. 2007-1775-AV of June 15, 2007
Chapter 4
Health Insurance Code of PR
§ 4.060(A)(1)(a)
2
COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
INDIVIDUAL MARKET
COMPANY: _________________________________________________________
FORM NUMBER: _________________________________________________________
REQUIREMENTS
Reference /Page/ Paragraph
§ 1602(2)
The style, arrangement and overall appearance of the policy shall give no undue prominence to any portion
of the text, and every printed portion of the text of the policy and of any endorsements or attached papers
shall be plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not
less than ten-point with a lower case unspaced alphabet length not less than one hundred and twenty-point.
§ 1602(3)
The exceptions and reductions of indemnity shall be set forth in the policy and, other than those contained in
§§ 1605 to 1628 of this title, inclusive, shall be printed, at the insurer's option, either included with the benefit
provision to which they apply, or under an appropriate caption such as "Exceptions" or "Exceptions and
reductions", except that if an exception or reduction specifically applies to a particular benefit of the policy, a
statement of such exception or reduction shall be included with the benefit provision to which it applies.
§ 1602(4)
Each form shall be identified by a form number in the lower left-hand corner of every page.
§ 1604
Except as provided in Section 11.130, each such policy delivered or issued for delivery to any person in
Puerto Rico shall contain the provisions as specified in Sections 16.050 through 16.090 inclusive, in the
words in which the same appear; except, that the insurer may, at its option, substitute for one or more of
such provisions corresponding provisions of different wording approved by the Commissioner which are in
each instance not less favorable in any respect to the insured or the beneficiary. Each such provision shall
be preceded by the applicable caption shown or, at the insurer’s option, by such appropriate individual or
group caption or sub caption as the Commissioner may approve.
§ 1605
Entire Contract Provision
§ 1607
Grace Period
§ 1608
Reinstatement Provision
§ 1609
Notice of Claim Provision (only applicable for reimbursement purpose)
§ 1610
Claim Forms Provision (only applicable for reimbursement purpose)
§ 1611
Proof of Loss Provision (only applicable for reimbursement purpose)
§ 1612
Time of Payment of Claims Provision (only applicable for reimbursement purpose)
§ 1613
Payment of Claims Provision (only applicable for reimbursement purpose)
§ 1615
Civil Actions Provision
§ 1629
Order of Certain Policy Provisions
The provisions which are the subject of §§ 1605--1628 of this title, inclusive, or any corresponding provisions
which are used in lieu thereof in accordance with such sections, shall be printed in the consecutive order of
the provisions in such sections or, at the insurer's option, any such provision may appear as a unit in any
part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall
not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to
whom the policy is offered, delivered or issued.
§ 1633
Family expenses disability insurance - Foster child definition
Chapter 4
Health Insurance Code
§ 4.060(A)(1)(B)
Information indicating which prescription drugs, if any, are subject to a management procedure that has
been developed and maintained pursuant to this Chapter must be disclosed in the policy or contract.
HEALTH INSURANCE CODE
REGULATION
Chapter 16
Insurance Code of Puerto
Rico
3 of 26
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
INDIVIDUAL MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
§ 4.060(A)(1)(C)
Information on how and what written documentation is required to be submitted in order for covered persons
or enrollees, or their authorized representatives, to file a request under the health insurance organization or
issuer ’s medical exceptions process established pursuant to Section 4.070 of this Chapter.
§ 4.060(A)(2)
The policy or contract shall establish that changes in the formulary or other prescription drug management
process during the term of the policy, certificate, or contract shall only be made if such change is being
made for safety reasons, because the prescription drug cannot be supplied or has been withdrawn from the
market by the drug’s manufacturer, or if such change entails the inclusion of prescription drugs in the
formulary.
§ 4.070
The policy or contract must include the Medical Exceptions Approval Process Requirements and
Procedures in accordance to Section 4.070.
§ 4.100
The policy, certificate, membership booklet, outline of coverage, evidence of coverage, or any other
document provided to a covered person or enrollee shall include the disclosures required in Section 4.100.
§ 4.120
The policy or contract must establish that when the history of the covered person or enrollee so requires,
insofar as it does not jeopardize the patient’s health, and at the discretion of the healthcare provider, such
healthcare provider may prescribe refills for maintenance drugs up to a term that shall not exceed one
hundred eighty (180) days, subject to the limitations of the health plan’s coverage.
§ 10.050(J)
§ 2.050(D)(3)
The individual health plan issuer shall file with the Commissioner the individual basic health plans in their
different metal levels of coverage, following the procedure established in Chapter 11 of the Insurance Code
of Puerto Rico and the format provided by the Commissioner through policy letter.
§ 10.050(M)
No individual health plan shall deny, exclude or limit the benefits of a covered person based on preexisting
conditions, regardless of the age of the enrollee.
§ 10.060
An individual health plan issuer shall be renewable or shall continue in force the coverage for the enrollee
and his/her dependent, at the option of the enrollee, and in accordance with the applicable Federal
regulations and legislation, except in the cases mentioned under this Section.
§ 10.080
The policy or contract must include a clause establishing the availability of Coverage in the Individual Market
in compliance with Section 10.080.
Chapter 12
Health Insurance Code
§ 12.040(A)
No policy, contract, certificate or agreement offered or issued in Puerto Rico by a health insurance
organization or issuer to provide, deliver, arrange for, pay for or reimburse any of the costs of healthcare
services may contain a provision purporting to reserve discretion to health insurance organizations or
issuers to interpret the terms of the contract, or to provide standards of interpretation or review that are
inconsistent with the laws of Puerto Rico. An adverse determination by a health insurance organization or
issuer, as well as disputes or controversies that may arise between a health insurance organization or issuer
and a covered person or enrollee, shall be subject to the internal and external review procedures established
in this Code.
§ 52.040(A)
A health plan that provides coverage for drugs shall provide for the dispensation of any drug covered,
regardless of the disorder, injury, illness, condition, or disease for which they were prescribed, provided, that
(1) the drug has been approved by the FDA for at least one indication, and (2) the drug is recognized for
treatment of the disorder, injury, illness, condition, or disease in one of the standard reference compendia or
in substantially accepted peer-reviewed medical literature.
§ 52.040(B)
Coverage of a drug shall also include medically necessary services associated with the administration of the
drug.
Chapter 4
Health Insurance Code
Chapter 10
health Insurance Code
Chapter 52
Health Insurance Code
4 of 26
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
INDIVIDUAL MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
§ 54.050(A)
Health plans that provide coverage for a dependent of a covered person or enrollee shall provide coverage
to:
(1) A newborn child of a covered person or enrollee from the moment of birth; or
(2) A newly adopted child of a covered person or enrollee from the earlier of dates mentioned in this Section.
§ 54.050(B)
The coverage for newborn and newly adopted children and children placed for adoption shall meet the
following requirements:
(1) Include coverage of injury or sickness healthcare services including the necessary care and treatment of
medically diagnosed congenital defects and birth abnormalities; and
(2) Is not subject to any preexisting condition exclusion.
§ 54.060(A)
If payment of a specific premium or subscription fee is required to provide coverage for a newborn child,
the health plan may require the covered person or enrollee to notify the health insurance organization or
issuer of the birth of the child and furnish payment of the required premium or fees within thirty (30) days
after the date of birth.
If notice and the payment described above are not provided, the health insurance organization or issuer may
refuse to continue coverage for the child under the health plan beyond the thirty (30)-day period. However, if
within four (4) months after the birth of the child the covered person or enrollee makes all past-due
payments, coverage shall be restored.
If payment of a specific premium or subscription fee is not required to provide coverage for a newborn child,
the health insurance organization or issuer may request notification of the birth of the child, but shall not
deny or refuse to continue coverage if the covered person or enrollee does not furnish the notice.
§ 54.060(B)
(1) If payment of a specific premium or subscription fee is required to provide coverage for a newly adopted
child or child placed for adoption, the health plan may require the covered person or enrollee to notify the
health insurance organization or issuer of the adoption or placement for adoption and furnish payment of the
required premium or fees within thirty (30) days after coverage is required to begin under Section
54.050A(2).
(2) If the covered person fails to provide the notice or make the payment described in the preceding
paragraph within the thirty (30)-day period, the health insurance organization or issuer shall treat the
adopted child or child placed for adoption no less favorably than it treats other dependents, other than
newborn children, who seek coverage at a time other than when the dependent was first eligible to apply for
coverage.
Chapter 72
Health Insurance Code
§ 72.040(A)
It is unfairly discriminatory to:
(1) Deny, refuse to issue, renew or reissue, cancel or otherwise terminate a health plan, or restrict a health
plan coverage or add a premium differential or surcharge to any health plan on the basis of the covered
person or enrollee’s abuse status; or
(2) Exclude, limit coverage, or deny a claim on the basis of the covered person or enrollee’s abuse status;
Chapter 54
Health Insurance Code
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
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REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
§ 1915(1)(c)
The coverage evidence shall be considered as deceptive if, as a whole, and taking into consideration the
typography and the format, as well as the language, it leads a person who has no special knowledge of
plans and coverage evidence to believe that he has benefits, services, charges or other advantages which
do not arise from the coverage evidence or which are not regularly accessible to the subscribers under the
health care plan which issues said coverage evidence.
§ 1915(4)
No health services organization may use in its name, contract or literature, any of the words "insurance",
"contingency", "guaranty", "mutual", or any other word describing insurance, contingency or guaranty
business, deceitfully similar to the name or description of any insurance or guaranty corporation doing
business in Puerto Rico.
Section 3(A)(g)
No insurer shall reject or deny any treatment agreed upon and/or included as part of the terms and
conditions of the health insurance contract signed by the parties when a medical recommendation to such
purposes so require. Physicians, health service organizations, insurers, and providers shall not reject or
deny treatment such as hospitalization, diagnosis, and medication to any cancer patient. With regard to
cancer survivors, insurers, health service organizations, and healthcare plans providers shall not deny
coverage for the treatment and frequent and permanent monitoring of the physical health and emotional
wellbeing of the insured.
Section 3(E)(c )
Coverage shall include pelvic exams and all types of vaginal cytology that may be required by a physician to
detect, diagnose, and treat early stages of abnormalities that may lead to Cervical Cancer.
Section 3(E)(d)
Every plan shall provide extended coverage for the payment of breast cancer screening and testing such as
visits to specialists, clinical breast exams, mammograms, digital mammograms, magnetic resonance
mammography and breast ultrasounds, and treatment including, but not limited to, mastectomy, breast
reconstruction after mastectomy, reconstructive surgery of the other breast to achieve symmetry, breast
prosthesis, treatment for physical complications at all stages of mastectomy, including lymphedema
(swelling that sometimes occurs after breast cancer treatment), any reconstructive surgery after mastectomy
that may be needed for the physical and emotional recovery of the patient.
Act No. 255
September 15, 2012
Health plan shall cover the vaccine against the human papilloma virus (HPV) for males and females;
according to the recommendations of the Advisory Committee on Immunization Practices (ACIP) and the
Centers for Disease Control and Prevention (CDC).
Act No. 239
September 13, 2012
Health plans shall include services provided by psychology professionals trained by education with a master
degree or PhD, trainings and experience to provide health care services, duly licensed by the Puerto Rico
Board of Psychologist Examiners.
Act No. 220
September 4, 2012
Section 15
Every plan shall provide coverage for the treatment of autism. This coverage should include, but not limited
to, genetics, neurology, immunology, gastroenterology and nutrition; speech, language, psychological,
occupational, and physical therapies; and will include physician office visit and the medical tests referred by
them.
Act No. 218
August 30, 2012
Sections 2 and 3
As part of their coverage insurers and HMO’s shall include, without this constituting a limitation, access to
tests of: Cancer, high blood pressure and cholesterol, diabetes, osteoporosis, and Sexually Transmitted
Diseases.
Act No. 107
June 5, 2012
Section 1
A health plan that provides coverage for treatment of chemotherapy against cancer must also provide
coverage of the chemotherapy against cancer in their various methods of administration of the drug, such as
intravenous, oral, injectable track or intrathecal route; according to the order of the specialist doctor or
oncologist.
Puerto Rico Laws
OTHER REQUIREMENTS FOR HEALTH SERVICES ORGANIZATIONS
Chapter 19 of the
Insurance Code
Act No. 275
September 27, 2012
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Reference /Page/ Paragraph
REGULATION
Section 6(i)
Have individual and group healthcare plans cover direct access to gynecology and obstetrics care services
without requiring referrals or previous authorization from the plan, insofar as such physician participates in
the network of the healthcare providers.
Section 6(j)
Have individual or group healthcare plans providing coverage for a minor as a participant or beneficiary allow
the parent or tutor of the dependent minor to select a pediatrician as his/her primary care provider, insofar
as such pediatrician participates in the network of healthcare providers.
Health care plans shall include the medication known as buprenorphine for treatment of opioid dependence
in the “Medicaid Preferred Drug List,” or the health plan preferred drug list.
Establishes that all health insurance shall provide, subject to preauthorization, coverage for one (1) bariatric
surgery per lifetime for the treatment of morbid obesity using one of the following techniques: gastric bypass,
adjustable gastric band or sleeve gastrectomy. The intragastric balloon technique is excluded from the law.
The health insurance may require a waiting period that shall not exceed twelve (12) months, before cover for
the benefits stipulated in this Act. For the preauthorization of these services, the first treatment for the
morbid obesity should be dietetic and in changes in the life style. The physician must document the
unsuccessful attempt(s) with nonoperative medically supervised weight reduction program(s).
For purposes of this Act No., morbid obesity means a body mass index of at least thirty-five (35) kilograms
per meter squared, or greater. Bariatric surgery refers to the various surgical procedures performed to treat
obesity, which can be practice by the following four techniques: gastric bypass, adjustable gastric band or
sleeve gastrectomy or intragastric balloon.
Amends Act No. 15 of February 27, 2007, in order to correct the scope of the measure and to extend the
term of effectiveness of said Act.
Provides that the underwriters of health insurance plans in the Commonwealth of Puerto Rico shall accept,
in a family insurance policy, the inclusion as beneficiaries of minors whose custody or guardianship has
been granted to the grandparents or other participating family members, and those of legal age who have
been declared disabled, whose guardianship has been granted, when the person to whom custody or
guardianship has been granted is the primary beneficiary or insured of said policy.
Act No. 21
February 29, 2008
Section 3
Health plans shall include as part of their coverage, if medically justified, in accordance with the criteria
established in the protocol created by virtue of this Act, the rendering of services, including medications, to
their subscribers who require tobacco and tobacco by-product use and dependence treatment, up to a
maximum of four hundred (400) dollars annually for each subscriber. (Only applies to HMO's)
Health plans shall provide access to the health services and treatment by a naturopathic physician if the
coverage provided by the health plan offers any service included in the "spectrum of practice" of a licensed
naturopathic physician, authorized by the Commonwealth of Puerto Rico.
Also, the policy or contract must disclose the applicable copay or coinsurance.
Health plans shall provide access to the health services and treatment by an audiologist if the coverage
provided by the health plan offers any service included in the "spectrum of practice" of a licensed audiologist
physician, authorized by the Commonwealth of Puerto Rico.
Also, the policy or contract must disclose the applicable copay or coinsurance.
Act No. 116 of
July 17, 2008
Act No. 140 of September 22, 2010
Act No. 212 of August 9, 2008
Act No. 210 of
December 14, 2007
Act No. 127 of
September 27, 2007
Act No. 161 of
November 1, 2010
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REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Health plans must include as part of their coverage, the technological equipment whose use may be
necessary to maintain the user alive, a minimum of one (1) daily eight (8) hour shift of nursing services
provided by skilled nurses knowledgeable in respiratory therapy or specialists in respiratory therapy with
nursing skills, the supplies needed to operate technological equipment and the physical and occupational
therapy needed to develop the motor skills of these patients. All of the preceding subject to having the need
established by a doctor’s order and according to the written home care plan for the patient.
For the purposes of this law, a beneficiary shall be understood to be a person under twenty-one (21) years
of age who uses medical technology whose functions depend on medical equipment, to wit, mechanical
ventilator via tracheotomy, which supplies the vital functions of the human body and which requires the
specialized daily care of nurses to prevent death or a greater degree of disability.
Establishes that all health insurance companies in the Commonwealth of Puerto Rico are hereby directed to
include the vaccine against respiratory syncytial virus as part of their pediatrics coverage.
Health plans shall provide access to the health services and treatment by a chiropractor, if the coverage
provided by the health plan offers any service included in the "spectrum of practice" of a licensed
chiropractor, authorized by the Commonwealth of Puerto Rico.
Also, the policy or contract must disclose the applicable copay or coinsurance.
Any health insurance policy which is available or may be available, renewed, extended, or modified in Puerto
Rico by any health insurance company with benefits applicable within the health insurance policy, shall
include coverage for initial hearing screening and for any other hearing evaluation within the follow-up care
related to the hearing screening described in this Act.
As provided by the act, the service shall be rendered in Puerto Rico even though the company is located
outside of Puerto Rico.
The benefits of the Universal Neonatal Hearing Screening Test to newborn babies, as well as the follow-up
care shall be subject to the same co-payment policies and co-insured provisions applicable to any other
medical service. With the exception that the benefit of neonatal hearing screening shall be exempted from
co-payments or provisions that limit the maximum amount to be paid by the insurer.
Act No. 148
August 9, 2002
Section 6(d)
Health plans shall provide access to the health services and treatment by a podiatrist, optometrist or
psychologist if the coverage provided by the health plan offers any service included in the "spectrum of
practice" of a licensed podiatrist, optometrist and clinical psychologist, authorized by the Commonwealth of
Puerto Rico.
Also, the policy or contract must disclose the applicable copay or coinsurance.
Act No. 125 of
September 21, 2007
Act No. 165 of
August 30, 2006
Act No. 150 of
August 8, 2006
Act No. 311 of December 19, 2003
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REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Establishes that any health insurance companies shall not favor nor instruct its insureds to exclusively
contact a medical emergency system other than 9-1-1 during an emergency. It is provided that any entity
subject to the provisions of this Act may use a transportation system other than 9-1-1, but cannot prohibit its
insured to contact the 9-1-1 system for non-emergency medical cases.
No entity subject to the provisions of this Act shall require its insureds or clients to obtain a pre-authorization
to contact the 9-1-1 system in case of a medical emergency. In addition, no entity subject to the provisions
of this Act may use false or deceitful language in the written material distributed to its insured or clients; or
language prohibiting them or making them desist from contacting the 9-1-1 system in case of a medical
emergency.
Section 6
Defines “Health Professional” as any practitioner duly allowed to practice in Puerto Rico, according to the
applicable Act and regulations, any of the health and medical care health professions including but not
limited to, physicians, surgeons, dentists, pharmacists, nurses and medical technologists, as authorized by
the corresponding Act of Puerto Rico.
Section 7(a)
All health care plans shall contain a clause providing that in cases in which health care plan coverage is
terminated or cancelled, or coverage by a provider is terminated or cancelled, the insurer shall notify the
patient of such termination or cancellation thirty (30) calendar days before the date such termination or
cancellation becomes effective.
Section 7(b)
The policy or contract shall contain a clause providing that subject to payment of premium as required,
should the plan or the provider terminate coverage, the patient may continue receiving the benefits thereof
for a transitional period of ninety (90) days as of the date the plan or the provider terminates coverage.
1. In those cases in which the patient is hospitalized at the time of the date of said termination of coverage,
and the release of the patient from the hospital has been scheduled for a date preceding the date of
termination of coverage, the transition period shall be extended from said date to ninety (90) days after the
date the patient is released.
2. In those cases in which the patient is in her second trimester of pregnancy as of the date of termination of
coverage and the provider has been offering medical treatment pertinent to the pregnancy before the date of
termination of coverage, the transitional period concerning pregnancy-related health care shall be extended
to the date the mother is released from hospital after childbirth, or the date the newborn is released from the
hospital, or both, whichever occurs later.
3. In those cases in which the patient is diagnosed a terminal condition before the date of termination of
coverage and the provider has been offering medical treatment pertinent to the condition before said date,
the transitional period shall be extended for the remainder of the patient’s life.
Providers that continue the treatment of the insured parties or their beneficiaries during said period must
accept the payments and rates fixed by the plan as full payment for services rendered, as well as continue
providing the plan with all the necessary information required by the plan for purposes of quality control, and
surrender or transfer the medical records corresponding to the patients upon termination of said transitional
period.
Act No. 383 of
September 6, 2000
Act No. 194
August 25, 2000
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INDIVIDUAL MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Section 8(c)
All health care plans in Puerto Rico shall provide emergency service benefits with no waiting period. The
previous authorization of the insurer shall not be required when providing these emergency services;
furthermore, these services shall be provided regardless of whether the provider of such emergency
services is a participating provider. In the event that a patient is provided services by a provider not
contracted by the insurer, the patient shall not be held liable for the payment of services in an amount
exceeding the amount applicable if the patient had received such services from a provider contracted by the
insurer. The insurer shall compensate the provider offering the services, and the provider shall be under the
obligation to accept said compensation, for an amount not to be less than the agreed with the providers
contracted by the insurer to offer the very same services. Moreover, under these circumstances, such
emergency services shall be provided regardless of the conditions set forth by the corresponding health care
plan.
Section 9(c)
All health plans shall contain a provision setting forth that the insurer shall pay the routine medical expenses
of any patient suffering from a life-threatening condition for which there is no effective treatment, when the
patient is eligible for participating in an authorized clinical treatment study pursuant to the study protocol
provisions concerning said treatment, provided the participation of the patient offers a potential benefit to the
patient and the physician referring the patient believes that participation in said study is pertinent, or the
patient presents evidence of the fact that participation in said study is pertinent. “Routine medical expenses
of the patient” shall not be construed to be expenses related to the study, or tests administered to be used
as part of the study, or expenses the entity conducting the study is likely to pay.
Any insurer that provides maternity benefits shall provide a minimum coverage of forty-eight (48) hours of
care in the hospital facilities in benefit of the mother and her newborn child (or children) if it is a natural birth
without complications, and a minimum of ninety-six (96) hours if she required a Caesarean section.
Any decision that has the effect of shortening the period of time provided above shall have to be determined
by the attending purveyor with the acceptance of the patient.
If the mother and the newborn are released within a period that is less than what is provided in this Section,
but in accordance with the second paragraph, the coverage shall provide for a follow-up visit within the next
forty-eight (48) hours. The services shall include, but shall not be limited to the attention and physical care of
the child, instruction on the care of the child for both parents, help and training on breast feeding,
information regarding home care, and the provision of any treatment, and medical tests for the infant as well
as for the mother.
Mental Health Parity Act
The services provided under the policy or contract regarding mental conditions must comply with the "Mental
Health Parity Act". There shall be no distinction between a mental disorder and any other medical condition
in terms of the access to the services that persons shall need. In addition, the policy or contract may not
include any limitations on visits to a psychiatrist, collateral visits, group therapy and residential treatments.
Patient Protection and
Affordable Care Act
(PPACA)
§§2704 and 1255 of the PHSA/
§1201 of the PPACA
Section 2.050(I) of the Health
Insurance Code of PR
Eliminate Pre-existing Condition Exclusions for Enrollees Under Age 19.
Act No. 248 of
August 15, 1999
Act No. 194
August 25, 2000
Federal Laws
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INDIVIDUAL MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
§ 2712 of the HSA/
§1001 of PPACA
45 CFR §147.128
Section 2.050(J) of the Health
Insurance Code of PR
Prohibit Rescissions – Coverage may only be rescinded for fraud or intentional misrepresentation of
material fact. Notification must be made to the policyholder 30 calendar days prior to cancellation.
§2711 of the PHSA/ §1001 of the
PPACA
Section 2.050 (A)(2) of the Health
Insurance Code
Act No. 161 of November 1, 2010
Eliminate Annual Dollar Limits on Essential Health Benefits
§2711 of the PHSA/ §1001 of the
PPACA
45CFR §147.126
Section 2.050(A)(1) of the Health
Insurance Code
Eliminate Lifetime Dollar Limits on Essential Health Benefits
§1302 of the PPACA
Maximum Out of Pocket- Requires establishment of a maximum cost sharing for Essential Health Benefits
§2713 of the PHSA/ §1001 of the
PPACA
45 CFR §147.130
Section 2.050(C) of the Health
Insurance Code
Act No. 161 of November 1, 2010
Preventive Services – Requires coverage and prohibits the imposition of cost-sharing for:
Services for children and adults with a rating of A or B by the U.S. Preventive Services Task Force.
Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for
Disease Control and Prevention and the "Comité Asesor en Practicas de Inmunización" of the Puerto Rico
Health Department.
Preventive care and screenings for infants, children and adolescents in guidelines supported by the
Health Resources and Services Administration. (IN PR 21 YEARS)
Preventive care and screenings for women in guidelines supported by the Health Resources and Services
Administration, including breast cancer screening, mammography and prevention.
§2714 of the PHSA/ §1001 of the
PPACA
26 CFR §§ 144.101,
146.101, 147.100, and 147.120
Extends Dependent Coverage for Children Until age 26 – If a policy offers dependent coverage, it must
include dependent coverage until age 26. (Coverage is not required for children of dependents.)
Also, the definition of "Dependent" must comply with Sections 2.030(G) and 10.030(H) of the Health
Insurance Code of Puerto Rico.
§2719 of the PHSA/ §1001 of the
PPACA
45 CFR §147.136
Appeals Process – Requires establishment of an internal claims appeal process and external review
process.
Also, the policy or contract must comply with Chapters 22, 24 and 28 of the Health Insurance Code.
Patient Protection and
Affordable Care Act
(PPACA)
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Reference /Page/ Paragraph
REGULATION
Patient Protection and
Affordable Care Act
(PPACA)
§2719A of the PHSA/ §10101 of
the PPACA
45 CFR § 147.138(b)
Emergency Services – Requires plans that cover emergency services to provide such coverage without the
need for prior authorization, regardless of the participating status of the provider, without imposing any
administrative requirement or limitation that is more restrictive than that required for participating provider
services, and at the in-network cost-sharing level.
In addition to the in-network cost-sharing, an enrollee / insured may be required to pay the excess of the
amount a non-participating provider charges over the greater of: (i) The amount the plan pays participating
providers for such services; (ii) The amount the plan pays non-participating providers for such services,
without reduction for out-of network cost-sharing or; (iii) the amount that would be paid under Medicare.
Emergency condition means a medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the
health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child)
in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ
or part.
Emergency service means a medical screening examination (as required under §1867 of the Social Security
Act) that is within the capability of the emergency department of a hospital; and within the
capabilities of the staff and facilities available at the hospital such further examination and treatment as
required under §1867 of the Social Security Act to stabilize the patient.
Stabilize means to provide such medical treatment of the condition as may be necessary to assure, within
reasonable medical probability, that no material deterioration of the condition is likely to result from or occur
during the transfer of the individual from a facility, or, with respect to an emergency medical condition, to
deliver (including the placenta).
Require that health plans must include the meningitis vaccine as part of the basic coverage.
Require that every Insurer, Health Services Organization and Non-Profit Association that underwrite health
insurance in Puerto Rico offer, as part of basic coverage, an annual medical evaluation that includes
preventive services required by Act No. 296 of September 1, 2000 without any cost beyond the premium
originally established for said plans.
The mentioned Act imposes to the Puerto Rico Department of Education the responsibility to ensure that
each child received an annual medical evaluation at the beginning of the school year. Said medical
evaluation must include physical and mental evaluation, oral hygiene, hearing and visual tests, as well as
periodic tests recommended by the American Academy of Pediatrics.
Requires that all health insurance shall estipulate that in such cases in which an insured or subscriber
decides to use a private hospital room instead of a semi-private room, he or she will be responsible for the
difference in cost that this utilization represents. In addition, all health insurance shall estipulate that unless
in the cases of differences in the cost of the hospital rooms, the providers cannot charge to patients in a
private rooms different quantities to those that have the rights to charge if said patient was confined in a
semi-private room.
Ruling Letter No. 2011-121-AV of September 1, 2011
Circular and Ruling Letters Applicable
Ruling Letter No. N-AV-7-8-2001 of July 6, 2001
Ruling Letter No. N-AV-12-111-99 of December 20, 1999
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REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Establishes that the Health Insurance Portability and Accountability Act (HIPAA) is applicable in our
jurisdiction and preempts the Insurance Code of Puerto Rico with regard to the provisions required in the
Act, which are not provided in said Code or which are less stringent than the federal requirements.
Requires that all health insurance that provides ambulance services in their coverage must estipulate that
the ambulance companies that will render the services must be authorized by the Puerto Rico Commission
of Public Services.
Regarding pregnant women, all insurers or health services organizations are required to cover and will not
impose cost-sharing requirements with regard to the following tests included in the most recent
recommendations of the “United States Preventive Services Task Force (USPSTF):
1) A first HIV test during the first trimester of pregnancy at the first prenatal visit, and
2) A second test during the third trimester of pregnancy (between the 28th and 34th week of pregnancy).
All insurers and health insurance organizations that provide health insurance to individuals and small groups
will have to include in such plans at a minimum essential health services known as Essential Health Benefits
(EHB). EHB include benefits and services in at least the following ten categories:
1. Out-patient services
2. Emergency services
3. Hospitalization
4. Laboratory services
5. Maternity and newborn care services
6. Mental health services and for controlled substance use disorder
7. Prescribed medication
8. Rehabilitation and habilitation services and equipment
9. Preventive, wellness, and management of chronic disease services
10. Pediatric services including vision and dental care
The EHB Benchmark Plan selected for Puerto Rico was Optimo Plus PPO.1 Exclusively with regard to
pediatric vision services, the rule provides for using the coverage of the Federal Employees Dental and
Vision Insurance Program (FEDVIP) to define the EHB that must be included in health insurance plans.
Chapter 11
Insurance Code of Puerto
Rico
Section 11.110(1)
The policy or contract shall include a coordination of benefit provision in compliance with the Coordination of
Benefit Model Regulation of the NAIC.
§ 17(D)(1)
Notice related to policies or certificates which are not Medicare Supplement Policies.
Appendix C
Disclosure Statements. Instructions for use of the disclosure statements for health insurance policies sold to
Medicare beneficiaries that duplicate Medicare.
The policy shall contain the name and full address of the issuing insurer or health organization on the front
cover.
The signature of company officer(s) appears prominently on the policy (such as on the cover).
As a requirement, the below certification must be completed, signed and included with the filing.
Circular Letter No. CC-2014-1848-AS of January 22, 2014
Circular Letter No. 2013-1825-D of March 1, 2013
and
Section 2.050(D)(3) of the Health Insurance Code of PR
Rule L of the Regulation of
the Insurance Code
ADDITIONAL REQUIREMENTS
Circular Letter No. 2007-1775-AV of June 15, 2007
Ruling Letter No. N-AV-10-90-97 of November 24, 1997
Ruling Letter No. N-C-8-71-95 of October 13, 1995
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INDIVIDUAL MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
CERTIFICATION
I ____________________________________ have reviewed or supervised the preparation of the above
form(s) and certify that the same comply with all of the applicable requirements of the Puerto Rico Form
Filing Check List and that the filing does not contain dispositions previously disapproved or required to be
corrected by the Office of the Commissioner of Insurance of Puerto Rico. I also acknowledge responsibility
for the validity, accuracy and completeness of the contents of the transmittal letter and enclosures with this
filing.
Signature: _____________________________________________________________________
Date: _____________________________________________________________________
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COMMONWEALTH OF PUERTO RICO
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PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
COMPANY: _________________________________________________________
FORM NUMBER: _________________________________________________________
REQUIREMENTS
Reference /Page/ Paragraph
§ 1701(3)
No group disability insurance policy shall be issued for delivery in Puerto Rico, unless it is in agreement
with one of the descriptions contained in in § 1401 of this title.
§ 1703
Grace Period Provision
§ 1706
Issuance of Certificates
§ 1707
Conversion provision
§ 4.060(A)(1)(B)
Information indicating which prescription drugs, if any, are subject to a management procedure that has
been developed and maintained pursuant to this Chapter must be disclosed in the policy or contract.
§ 4.060(A)(1)(C)
Information on how and what written documentation is required to be submitted in order for covered
persons or enrollees, or their authorized representatives, to file a request under the health insurance
organization or issuer ’s medical exceptions process established pursuant to Section 4.070 of this
Chapter.
§ 4.060(A)(2)
The policy or contract shall establish that changes in the formulary or other prescription drug
management process during the term of the policy, certificate, or contract shall only be made if such
change is being made for safety reasons, because the prescription drug cannot be supplied or has
been withdrawn from the market by the drug’s manufacturer, or if such change entails the inclusion of
prescription drugs in the formulary.
§ 4.070
The policy or contract must include the Medical Exceptions Approval Process Requirements and
Procedures in accordance to Section 4.070.
§ 4.100
The policy, certificate, membership booklet, outline of coverage, evidence of coverage, or any other
document provided to a covered person or enrollee shall include the disclosures required in Section
4.100.
§ 4.120
The policy or contract must establish that when the history of the covered person or enrollee so
requires, insofar as it does not jeopardize the patient’s health, and at the discretion of the healthcare
provider, such healthcare provider may prescribe refills for maintenance drugs up to a term that shall
not exceed one hundred eighty (180) days, subject to the limitations of the health plan’s coverage.
§ 8.030(K)
The Small- and Medium-sized Business (PYMES) Employer definition must be in compliance with this
Section.
§ 8.030(L)
Health plans with waiting periods must define the term ‘Waiting Period’ as the period of time that must
pass before coverage for a covered person or enrollee who is otherwise eligible to enroll under the
terms of a health plan can become effective. In no case the waiting period shall exceed ninety (90)
days.
§ 8.060
The policy or contract shall include the renewal requirements in compliance with this Section.
§ 8.070(c)(4)
Health plans shall not deny, exclude or limit benefits for a person due to a preexisting condition
regardless of the person’s age.
REGULATION
HEALTH INSURANCE CODE
Chapter 8
Health Insurance Code
Chapter 17 of the Insurance Code
Chapter 4
Health Insurance Code
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Chapter 12
Health Insurance Code
§ 12.040(A)
No policy, contract, certificate or agreement offered or issued in Puerto Rico by a health insurance
organization or issuer to provide, deliver, arrange for, pay for or reimburse any of the costs of
healthcare services may contain a provision purporting to reserve discretion to health insurance
organizations or issuers to interpret the terms of the contract, or to provide standards of interpretation
or review that are inconsistent with the laws of Puerto Rico. An adverse determination by a health
insurance organization or issuer, as well as disputes or controversies that may arise between a health
insurance organization or issuer and a covered person or enrollee, shall be subject to the internal and
external review procedures established in this Code.
§ 52.040(A)
A health plan that provides coverage for drugs shall provide for the dispensation of any drug covered,
regardless of the disorder, injury, illness, condition, or disease for which they were prescribed,
provided, that (1) the drug has been approved by the FDA for at least one indication, and (2) the drug is
recognized for treatment of the disorder, injury, illness, condition, or disease in one of the standard
reference compendia or in substantially accepted peer-reviewed medical literature.
§ 52.040(B)
Coverage of a drug shall also include medically necessary services associated with the administration
of the drug.
§ 54.050(A)
Health plans that provide coverage for a dependent of a covered person or enrollee shall provide
coverage to:
(1) A newborn child of a covered person or enrollee from the moment of birth; or
(2) A newly adopted child of a covered person or enrollee from the earlier of dates mentioned in this
Section.
§ 54.050(B)
The coverage for newborn and newly adopted children and children placed for adoption shall meet the
following requirements:
(1) Include coverage of injury or sickness healthcare services including the necessary care and
treatment of medically diagnosed congenital defects and birth abnormalities; and
(2) Is not subject to any preexisting condition exclusion.
§ 54.060(A)
If payment of a specific premium or subscription fee is required to provide coverage for a newborn
child, the health plan may require the covered person or enrollee to notify the health insurance
organization or issuer of the birth of the child and furnish payment of the required premium or fees
within thirty (30) days after the date of birth.
If notice and the payment described above are not provided, the health insurance organization or issuer
may refuse to continue coverage for the child under the health plan beyond the thirty (30)-day period.
However, if within four (4) months after the birth of the child the covered person or enrollee makes all
past-due payments, coverage shall be restored.
If payment of a specific premium or subscription fee is not required to provide coverage for a newborn
child, the health insurance organization or issuer may request notification of the birth of the child, but
shall not deny or refuse to continue coverage if the covered person or enrollee does not furnish the
notice.
Chapter 52
Health Insurance Code
Chapter 54
Health Insurance Code
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Chapter 54
Health Insurance Code
§ 54.060(B)
(1) If payment of a specific premium or subscription fee is required to provide coverage for a newly
adopted child or child placed for adoption, the health plan may require the covered person or
enrollee to notify the health insurance organization or issuer of the adoption or placement for adoption
and furnish payment of the required premium or fees within thirty (30) days after coverage is required to
begin under Section 54.050A(2).
(2) If the covered person fails to provide the notice or make the payment described in the preceding
paragraph within the thirty (30)-day period, the health insurance organization or issuer shall treat the
adopted child or child placed for adoption no less favorably than it treats other dependents, other than
newborn children, who seek coverage at a time other than when the dependent was first eligible to
apply for coverage.
§ 72.040(A)
It is unfairly discriminatory to:
(1) Deny, refuse to issue, renew or reissue, cancel or otherwise terminate a health plan, or restrict a
health plan coverage or add a premium differential or surcharge to any health plan on the basis of the
covered person or enrollee’s abuse status; or
(2) Exclude, limit coverage, or deny a claim on the basis of the covered person or enrollee’s abuse
status;
§ 72.040(D)
It is unfairly discriminatory to terminate group coverage for a victim of abuse because coverage was
originally issued in the name of the abuser and the abuser has divorced, separated from, or lost
custody of the victim of abuse, or the abuser’s coverage has terminated voluntarily or involuntarily.
Nothing in this subsection prohibits the health insurance organization or issuer or insurance
professional from requiring the victim of abuse to pay the full premium for coverage under the health
plan or from requiring as a condition of coverage that the victim of abuse reside or work within the
health plan service area, if the requirements are applied to all existing or potential covered persons or
enrollees. The health insurance organization or issuer may terminate group coverage after the
continuation coverage required by this subsection has been in force for eighteen (18) months, if it offers
conversion to an equivalent individual plan. The continuation coverage required herein shall be satisfied
by coverage required under the ‘Consolidated Omnibus Budget Reconciliation Act of 1985’ (COBRA),
and shall not be in addition to coverage provided under COBRA.
§ 1915(1)(c)
The coverage evidence shall be considered as deceptive if, as a whole, and taking into consideration
the typography and the format, as well as the language, it leads a person who has no special
knowledge of plans and coverage evidence to believe that he has benefits, services, charges or other
advantages which do not arise from the coverage evidence or which are not regularly accessible to the
subscribers under the health care plan which issues said coverage evidence.
§ 1915(4)
No health services organization may use in its name, contract or literature, any of the words
"insurance", "contingency", "guaranty", "mutual", or any other word describing insurance, contingency
or guaranty business, deceitfully similar to the name or description of any insurance or guaranty
corporation doing business in Puerto Rico.
Chapter 72
Health Insurance Code
OTHER REQUIREMENTS FOR HEALTH SERVICES ORGANIZATIONS
Chapter 19 of the Insurance Code
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COMMONWEALTH OF PUERTO RICO
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SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Section 3(A)(g)
No insurer shall reject or deny any treatment agreed upon and/or included as part of the terms and
conditions of the health insurance contract signed by the parties when a medical recommendation to
such purposes so require. Physicians, health service organizations, insurers, and providers shall not
reject or deny treatment such as hospitalization, diagnosis, and medication to any cancer patient. With
regard to cancer survivors, insurers, health service organizations, and healthcare plans providers shall
not deny coverage for the treatment and frequent and permanent monitoring of the physical health and
emotional wellbeing of the insured.
Section 3(E)(c )
Coverage shall include pelvic exams and all types of vaginal cytology that may be required by a
physician to detect, diagnose, and treat early stages of abnormalities that may lead to Cervical Cancer.
Section 3(E)(d)
Every plan shall provide extended coverage for the payment of breast cancer screening and testing
such as visits to specialists, clinical breast exams, mammograms, digital mammograms, magnetic
resonance mammography and breast ultrasounds, and treatment including, but not limited to,
mastectomy, breast reconstruction after mastectomy, reconstructive surgery of the other breast to
achieve symmetry, breast prosthesis, treatment for physical complications at all stages of mastectomy,
including
lymphedema
(swelling
that
sometimes
occurs
after
breast
cancer
treatment),
any
reconstructive surgery after mastectomy that may be needed for the physical and emotional recovery of
the patient.
Act No. 255
September 15, 2012
Health plan shall cover the vaccine against the human papilloma virus (HPV) for males and females;
according to the recommendations of the Advisory Committee on Immunization Practices (ACIP) and
the Centers for Disease Control and Prevention (CDC).
Act No. 239
September 13, 2012
Health plans shall include services provided by psychology professionals trained by education with a
master degree or PhD, trainings and experience to provide health care services, duly licensed by the
Puerto Rico Board of Psychologist Examiners.
Act No. 220
September 4, 2012
Section 15
Every plan shall provide coverage for the treatment of autism. This coverage should include, but not
limited to, genetics, neurology, immunology, gastroenterology and nutrition; speech, language,
psychological, occupational, and physical therapies; and will include physician office visit and the
medical tests referred by them.
Act No. 218
August 30, 2012
Sections 2 and 3
As part of their coverage insurers and HMO’s shall include, without this constituting a limitation, access
to tests of: Cancer, high blood pressure and cholesterol, diabetes, osteoporosis, and Sexually
Transmitted Diseases.
Act No. 107
June 5, 2012
Section 1
A health plan that provides coverage for treatment of chemotherapy against cancer must also provide
coverage of the chemotherapy against cancer in their various methods of administration of the drug,
such as intravenous, oral, injectable track or intrathecal route; according to the order of the specialist
doctor or oncologist.
Section 6(i)
Have individual and group healthcare plans cover direct access to gynecology and obstetrics care
services without requiring referrals or previous authorization from the plan, insofar as such physician
participates in the network of the healthcare providers.
Section 6(j)
Have individual or group healthcare plans providing coverage for a minor as a participant or beneficiary
allow the parent or tutor of the dependent minor to select a pediatrician as his/her primary care
provider, insofar as such pediatrician participates in the network of healthcare providers.
Health care plans shall include the medication known as buprenorphine for treatment of opioid
dependence in the “Medicaid Preferred Drug List,” or the health plan preferred drug list.
Act No. 161 of
November 1, 2010
Act No. 140 of September 22, 2010
Puerto Rico Laws
Act No. 275
September 27, 2012
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OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Establishes that all health insurance shall provide, subject to preauthorization, coverage for one (1)
bariatric surgery per lifetime for the treatment of morbid obesity using one of the following techniques:
gastric bypass, adjustable gastric band or sleeve gastrectomy. The intragastric balloon technique is
excluded from the law.
The health insurance may require a waiting period that shall not exceed twelve (12) months, before
cover for the benefits stipulated in this Act. For the preauthorization of these services, the first
treatment for the morbid obesity should be dietetic and in changes in the life style. The physician must
document the unsuccessful attempt(s) with nonoperative medically supervised weight reduction
program(s).
For purposes of this Act No., morbid obesity means a body mass index of at least thirty-five (35)
kilograms per meter squared, or greater. Bariatric surgery refers to the various surgical procedures
performed to treat obesity, which can be practice by the following four techniques: gastric bypass,
adjustable gastric band or sleeve gastrectomy or intragastric balloon.
Amends Act No. 15 of February 27, 2007, in order to correct the scope of the measure and to extend
the term of effectiveness of said Act.
Provides that the underwriters of health insurance plans in the Commonwealth of Puerto Rico shall
accept, in a family insurance policy, the inclusion as beneficiaries of minors whose custody or
guardianship has been granted to the grandparents or other participating family members, and those of
legal age who have been declared disabled, whose guardianship has been granted, when the person to
whom custody or guardianship has been granted is the primary beneficiary or insured of said policy.
Act No. 21
February 29, 2008
Section 3
Health plans shall include as part of their coverage, if medically justified, in accordance with the criteria
established in the protocol created by virtue of this Act, the rendering of services, including
medications, to their subscribers who require tobacco and tobacco by-product use and dependence
treatment, up to a maximum of four hundred (400) dollars annually for each subscriber. (Only applies
to HMO's)
Health plans shall provide access to the health services and treatment by a naturopathic physician if
the coverage provided by the health plan offers any service included in the "spectrum of practice" of a
licensed naturopathic physician, authorized by the Commonwealth of Puerto Rico.
Also, the policy or contract must disclose the applicable copay or coinsurance.
Health plans shall provide access to the health services and treatment by an audiologist if the coverage
provided by the health plan offers any service included in the "spectrum of practice" of a licensed
audiologist physician, authorized by the Commonwealth of Puerto Rico.
Also, the policy or contract must disclose the applicable copay or coinsurance.
Act No. 212 of August 9, 2008
Act No. 116 of
July 17, 2008
Act No. 210 of
December 14, 2007
Act No. 127 of
September 27, 2007
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Health plans must include as part of their coverage, the technological equipment whose use may be
necessary to maintain the user alive, a minimum of one (1) daily eight (8) hour shift of nursing services
provided by skilled nurses knowledgeable in respiratory therapy or specialists in respiratory therapy
with nursing skills, the supplies needed to operate technological equipment and the physical and
occupational therapy needed to develop the motor skills of these patients. All of the preceding subject
to having the need established by a doctor’s order and according to the written home care plan for the
patient.
For the purposes of this law, a beneficiary shall be understood to be a person under twenty-one (21)
years of age who uses medical technology whose functions depend on medical equipment, to wit,
mechanical ventilator via tracheotomy, which supplies the vital functions of the human body and which
requires the specialized daily care of nurses to prevent death or a greater degree of disability.
Establishes that all health insurance companies in the Commonwealth of Puerto Rico are hereby
directed to include the vaccine against respiratory syncytial virus as part of their pediatrics coverage.
Health plans shall provide access to the health services and treatment by a chiropractor, if the
coverage provided by the health plan offers any service included in the "spectrum of practice" of a
licensed chiropractor, authorized by the Commonwealth of Puerto Rico.
Also, the policy or contract must disclose the applicable copay or coinsurance.
Any health insurance policy which is available or may be available, renewed, extended, or modified in
Puerto Rico by any health insurance company with benefits applicable within the health insurance
policy, shall include coverage for initial hearing screening and for any other hearing evaluation within
the follow-up care related to the hearing screening described in this Act.
As provided by the act, the service shall be rendered in Puerto Rico even though the company is
located outside of Puerto Rico.
The benefits of the Universal Neonatal Hearing Screening Test to newborn babies, as well as the followup care shall be subject to the same co-payment policies and co-insured provisions applicable to any
other medical service. With the exception that the benefit of neonatal hearing screening shall be
exempted from co-payments or provisions that limit the maximum amount to be paid by the insurer.
Act No. 148
August 9, 2002
Section 6(d)
Health plans shall provide access to the health services and treatment by a podiatrist, optometrist or
psychologist if the coverage provided by the health plan offers any service included in the "spectrum of
practice" of a licensed podiatrist, optometrist and clinical psychologist, authorized by the
Commonwealth of Puerto Rico.
Also, the policy or contract must disclose the applicable copay or coinsurance.
Act No. 125 of
September 21, 2007
Act No. 165 of
August 30, 2006
Act No. 150 of
August 8, 2006
Act No. 311 of December 19, 2003
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Establishes that any health insurance companies shall not favor nor instruct its insureds to exclusively
contact a medical emergency system other than 9-1-1 during an emergency. It is provided that any
entity subject to the provisions of this Act may use a transportation system other than 9-1-1, but cannot
prohibit its insured to contact the 9-1-1 system for non-emergency medical cases.
No entity subject to the provisions of this Act shall require its insureds or clients to obtain a preauthorization to contact the 9-1-1 system in case of a medical emergency. In addition, no entity subject
to the provisions of this Act may use false or deceitful language in the written material distributed to its
insured or clients; or language prohibiting them or making them desist from contacting the 9-1-1
system in case of a medical emergency.
Section 6
Defines “Health Professional” as any practitioner duly allowed to practice in Puerto Rico, according to
the applicable Act and regulations, any of the health and medical care health professions including but
not limited to, physicians, surgeons, dentists, pharmacists, nurses and medical technologists, as
authorized by the corresponding Act of Puerto Rico.
Section 7(a)
All health care plans shall contain a clause providing that in cases in which health care plan coverage is
terminated or cancelled, or coverage by a provider is terminated or cancelled, the insurer shall notify
the patient of such termination or cancellation thirty (30) calendar days before the date such
termination or cancellation becomes effective.
Section 7(b)
The policy or contract shall contain a clause providing that subject to payment of premium as required,
should the plan or the provider terminate coverage, the patient may continue receiving the benefits
thereof for a transitional period of ninety (90) days as of the date the plan or the provider terminates
coverage.
1. In those cases in which the patient is hospitalized at the time of the date of said termination of
coverage, and the release of the patient from the hospital has been scheduled for a date preceding the
date of termination of coverage, the transition period shall be extended from said date to ninety (90)
days after the date the patient is released.
2. In those cases in which the patient is in her second trimester of pregnancy as of the date of
termination of coverage and the provider has been offering medical treatment pertinent to the
pregnancy before the date of termination of coverage, the transitional period concerning pregnancyrelated health care shall be extended to the date the mother is released from hospital after childbirth, or
the date the newborn is released from the hospital, or both, whichever occurs later.
3. In those cases in which the patient is diagnosed a terminal condition before the date of termination of
coverage and the provider has been offering medical treatment pertinent to the condition before said
date, the transitional period shall be extended for the remainder of the patient’s life.
Providers that continue the treatment of the insured parties or their beneficiaries during said period
must accept the payments and rates fixed by the plan as full payment for services rendered, as well as
continue providing the plan with all the necessary information required by the plan for purposes of
quality control, and surrender or transfer the medical records corresponding to the patients upon
termination of said transitional period.
Act No. 194
August 25, 2000
Act No. 194
August 25, 2000
Act No. 383 of
September 6, 2000
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Section 8(c)
All health care plans in Puerto Rico shall provide emergency service benefits with no waiting period.
The previous authorization of the insurer shall not be required when providing these emergency
services; furthermore, these services shall be provided regardless of whether the provider of such
emergency services is a participating provider. In the event that a patient is provided services by a
provider not contracted by the insurer, the patient shall not be held liable for the payment of services in
an amount exceeding the amount applicable if the patient had received such services from a provider
contracted by the insurer. The insurer shall compensate the provider offering the services, and the
provider shall be under the obligation to accept said compensation, for an amount not to be less than
the agreed with the providers contracted by the insurer to offer the very same services. Moreover,
under these circumstances, such emergency services shall be provided regardless of the conditions
set forth by the corresponding health care plan.
Section 9(c)
All health plans shall contain a provision setting forth that the insurer shall pay the routine medical
expenses of any patient suffering from a life-threatening condition for which there is no effective
treatment, when the patient is eligible for participating in an authorized clinical treatment study pursuant
to the study protocol provisions concerning said treatment, provided the participation of the patient
offers a potential benefit to the patient and the physician referring the patient believes that participation
in said study is pertinent, or the patient presents evidence of the fact that participation in said study is
pertinent. “Routine medical expenses of the patient” shall not be construed to be expenses related to
the study, or tests administered to be used as part of the study, or expenses the entity conducting the
study is likely to pay.
Any insurer that provides maternity benefits shall provide a minimum coverage of forty-eight (48) hours
of care in the hospital facilities in benefit of the mother and her newborn child (or children) if it is a
natural birth without complications, and a minimum of ninety-six (96) hours if she required a Caesarean
section.
Any decision that has the effect of shortening the period of time provided above shall have to be
determined by the attending purveyor with the acceptance of the patient.
If the mother and the newborn are released within a period that is less than what is provided in this
Section, but in accordance with the second paragraph, the coverage shall provide for a follow-up visit
within the next forty-eight (48) hours. The services shall include, but shall not be limited to the attention
and physical care of the child, instruction on the care of the child for both parents, help and training on
breast feeding, information regarding home care, and the provision of any treatment, and medical tests
for the infant as well as for the mother.
Mental Health Parity Act
The services provided under the policy or contract regarding mental conditions must comply with the
"Mental Health Parity Act". There shall be no distinction between a mental disorder and any other
medical condition in terms of the access to the services that persons shall need. In addition, the policy
or contract may not include any limitations on visits to a psychiatrist, collateral visits, group therapy and
residential treatments.
§§2704 and 1255 of the PHSA/
§1201 of the PPACA
Section 2.050(I) of the Health
Insurance Code of PR
Eliminate Pre-existing Condition Exclusions for Enrollees Under Age 19.
Act No. 248 of
August 15, 1999
Federal Laws
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
§ 2712 of the HSA/
§1001 of PPACA
45 CFR §147.128
Section 2.050(J) of the Health
Insurance Code of PR
Prohibit Rescissions – Coverage may only be rescinded for fraud or intentional misrepresentation of
material fact. Notification must be made to the policyholder 30 calendar days prior to cancellation.
§2711 of the PHSA/ §1001 of the
PPACA
Section 2.050 (A)(2) of the Health
Insurance Code
Act No. 161 of November 1, 2010
Eliminate Annual Dollar Limits on Essential Health Benefits
§2711 of the PHSA/ §1001 of the
PPACA
45CFR §147.126
Section 2.050(A)(1) of the Health
Insurance Code
Eliminate Lifetime Dollar Limits on Essential Health Benefits
§1302 of the PPACA
Maximum Out of Pocket- Requires establishment of a maximum cost sharing for Essential Health
Benefits
§2713 of the PHSA/ §1001 of the
PPACA
45 CFR §147.130
Section 2.050(C) of the Health
Insurance Code
Act No. 161 of November 1, 2010
Preventive Services – Requires coverage and prohibits the imposition of cost-sharing for:
Services for children and adults with a rating of A or B by the U.S. Preventive Services Task Force.
Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers
for Disease Control and Prevention and the "Comité Asesor en Practicas de Inmunización" of the
Puerto Rico Health Department.
Preventive care and screenings for infants, children and adolescents in guidelines supported by the
Health Resources and Services Administration. (IN PR 21 YEARS)
Preventive care and screenings for women in guidelines supported by the Health Resources and
Services Administration, including breast cancer screening, mammography and prevention.
§2714 of the PHSA/ §1001 of the
PPACA
26 CFR §§ 144.101,
146.101, 147.100, and 147.120
Extends Dependent Coverage for Children Until age 26 – If a policy offers dependent coverage, it
must include dependent coverage until age 26. (Coverage is not required for children of dependents.)
Also, the definition of "Dependent" must comply with Sections 2.030(G) and 10.030(H) of the Health
Insurance Code of Puerto Rico.
§2719 of the PHSA/ §1001 of the
PPACA
45 CFR §147.136
Appeals Process – Requires establishment of an internal claims appeal process and external review
process.
Also, the policy or contract must comply with Chapters 22, 24 and 28 of the Health Insurance Code.
Patient Protection and Affordable
Care Act (PPACA)
Patient Protection and Affordable
Care Act (PPACA)
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
§2719A of the PHSA/ §10101 of
the PPACA
45 CFR § 147.138(b)
Emergency Services – Requires plans that cover emergency services to provide such coverage
without the need for prior authorization, regardless of the participating status of the provider, without
imposing any administrative requirement or limitation that is more restrictive than that required for
participating provider services, and at the in-network cost-sharing level.
In addition to the in-network cost-sharing, an enrollee / insured may be required to pay the excess of
the amount a non-participating provider charges over the greater of: (i) The amount the plan pays
participating providers for such services; (ii) The amount the plan pays non-participating providers for
such services, without reduction for out-of network cost-sharing or; (iii) the amount that would be paid
under Medicare.
Emergency condition means a medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent layperson, who possesses an average knowledge
of health and medicine, could reasonably expect the absence of immediate medical attention to result
in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious
dysfunction of any bodily organ or part.
Emergency service means a medical screening examination (as required under §1867 of the Social
Security Act) that is within the capability of the emergency department of a hospital; and within the
capabilities of the staff and facilities available at the hospital such further examination and treatment as
required under §1867 of the Social Security Act to stabilize the patient.
Stabilize means to provide such medical treatment of the condition as may be necessary to assure,
within reasonable medical probability, that no material deterioration of the condition is likely to result
from or occur during the transfer of the individual from a facility, or, with respect to an emergency
medical condition, to deliver (including the placenta).
Require that health plans must include the meningitis vaccine as part of the basic coverage.
Require that every Insurer, Health Services Organization and Non-Profit Association that underwrite
health insurance in Puerto Rico offer, as part of basic coverage, an annual medical evaluation that
includes preventive services required by Act No. 296 of September 1, 2000 without any cost beyond
the premium originally established for said plans.
The mentioned Act imposes to the Puerto Rico Department of Education the responsibility to ensure
that each child received an annual medical evaluation at the beginning of the school year. Said medical
evaluation must include physical and mental evaluation, oral hygiene, hearing and visual tests, as well
as periodic tests recommended by the American Academy of Pediatrics.
Requires that all health insurance shall estipulate that in such cases in which an insured or subscriber
decides to use a private hospital room instead of a semi-private room, he or she will be responsible for
the difference in cost that this utilization represents. In addition, all health insurance shall estipulate that
unless in the cases of differences in the cost of the hospital rooms, the providers cannot charge to
patients in a private rooms different quantities to those that have the rights to charge if said patient was
confined in a semi-private room.
Circular and Ruling Letters Applicable
Ruling Letter No. 2011-121-AV of September 1, 2011
Ruling Letter No. N-AV-7-8-2001 of July 6, 2001
Ruling Letter No. N-AV-12-111-99 of December 20, 1999
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COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
Establishes that the Health Insurance Portability and Accountability Act (HIPAA) is applicable in our
jurisdiction and preempts the Insurance Code of Puerto Rico with regard to the provisions required in
the Act, which are not provided in said Code or which are less stringent than the federal requirements.
Requires that all health insurance that provides ambulance services in their coverage must estipulate
that the ambulance companies that will render the services must be authorized by the Puerto Rico
Commission of Public Services.
Regarding pregnant women, all insurers or health services organizations are required to cover and will
not impose cost-sharing requirements with regard to the following tests included in the most recent
recommendations of the “United States Preventive Services Task Force (USPSTF):
1) A first HIV test during the first trimester of pregnancy at the first prenatal visit, and
2) A second test during the third trimester of pregnancy (between the 28th and 34th week of
pregnancy).
All insurers and health insurance organizations that provide health insurance to individuals and small
groups will have to include in such plans at a minimum essential health services known as Essential
Health Benefits (EHB). EHB include benefits and services in at least the following ten categories:
1. Out-patient services
2. Emergency services
3. Hospitalization
4. Laboratory services
5. Maternity and newborn care services
6. Mental health services and for controlled substance use disorder
7. Prescribed medication
8. Rehabilitation and habilitation services and equipment
9. Preventive, wellness, and management of chronic disease services
10. Pediatric services including vision and dental care
The EHB Benchmark Plan selected for Puerto Rico was Optimo Plus PPO.1 Exclusively with regard to
pediatric vision services, the rule provides for using the coverage of the Federal Employees Dental and
Vision Insurance Program (FEDVIP) to define the EHB that must be included in health insurance plans.
Chapter 11
Insurance Code of Puerto Rico
Section 11.110(1)
The policy or contract shall include a coordination of benefit provision in compliance with the
Coordination of Benefit Model Regulation of the NAIC.
§ 17(D)(1)
Notice related to policies or certificates which are not Medicare Supplement Policies.
Appendix C
Disclosure Statements. Instructions for use of the disclosure statements for health insurance policies
sold to Medicare beneficiaries that duplicate Medicare.
The policy shall contain the name and full address of the issuing insurer or health organization on the
front cover.
The signature of company officer(s) appears prominently on the policy (such as on the cover).
Ruling Letter No. N-C-8-71-95 of October 13, 1995
Circular Letter No. CC-2014-1848-AS of January 22, 2014
Circular Letter No. 2013-1825-D of March 1, 2013
and
Section 2.050(D)(3) of the Health Insurance Code of PR
ADDITIONAL REQUIREMENTS
Rule L of the Regulation of the
Insurance Code
Ruling Letter No. N-AV-10-90-97 of November 24, 1997
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OCI Rev. March 2014
COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
PUERTO RICO FORM FILING CHECK LIST
SMALL GROUP MARKET
REQUIREMENTS
Reference /Page/ Paragraph
REGULATION
As a requirement, the below certification must be completed, signed and included with the filing.
CERTIFICATION
I ____________________________________ have reviewed or supervised the preparation of the
above form(s) and certify that the same comply with all of the applicable requirements of the Puerto
Rico Forms Filing Check List and that the filing does not contain dispositions previously disapproved or
required to be corrected by the Office of the Commissioner of Insurance of Puerto Rico.
I also
acknowledge responsibility for the validity, accuracy and completeness of the contents of the
transmittal letter and enclosures with this filing.
Signature: _____________________________________________________________________
Date: _____________________________________________________________________
Circular Letter No. 2007-1775-AV of June 15, 2007
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Attachment 8
Carrier Name
Cubierta Metálica
Cubierta Metálica
Cubierta Metálica
Tabla de Copagos, Coaseguros y Deducibles
Nombre del Plan
Nombre del Plan
Nombre del Plan
Deducible y Máximo de Bolsillo (MOOP)
Deducible Anual para Beneficios Medicos
-Individual
-Familiar
Deducible Anual para Medicamentos Recetados
Especializados, Biotechnicos y Marca No Preferida
-Individual
-Familiar
Deducible Anual para Medicamentos Recetados
Generico, Bioequivalente o Marca Preferida
-Individual
-Familiar
Gasto Maximo de Bolsillo (MOOP) para Beneficios Medicos
-Individual
-Familiar
Gasto Maximo de Bolsillo (MOOP) para Medicamentos Recetados
-Individual
-Familiar
Beneficios Esenciales de Salud
Servicios de Emergencia
-Accidente
-Enfermedad
Hospitalización
-Parcial incluyendo Salud Mental
-Completa con Pre-Autorización (incluyendo Salud Mental)
-Completa sin Pre-Autorización (incluyendo Salud Mental)
-Facilidad de Enfermeria Especializada (Skilled Nursing Facility)
-Asistencia Quirurgica
Servicios Ambulatorios
-Generalista
-Especialista
-Sub-Especialista
-Siquiatria
-Sicólogo
-Podiatria
-Quiropráctico
-Audiologo
-Optómetra
-Facilidad Ambulatoria
-Procedimientos Diagnósticos y Quirúrgicos en Oficina Medica
-Procedimientos Endoscopicos
Servicios de Rehabilitación, Habilitación, y Equipo Medico Duradero
-Terapia Fisica
-Terapia Respiratoria
-Cuidado de Salud en el Hogar
-Equipo Médico Duradero
-Manipulaciones de Quiropráctico
Salud Mental
-Terapia de Grupo
-Visitas Colaterales
Farmacia
-Generico Bioequivalente
-Marca Preferida
-Marca No Preferida
-Productos Especializados
-Medicamentos Fuera del Recetario (OTC)
Programa de Medicamentos Por Correo
-Generico Bioequivalente
-Marca Preferida
-Marca No Preferida
Servicios de Laboratorios y Rayos X
-Laboratorio
-Rayos X
-PET Scan o PET CT (1 por año)
Servicios Preventivos, Bienestar y Manejo de Enfermedades Crónicas
-Servicios Preventivos (incluyendo las de mujer)
-Inmunizaciones (Vacunas) Preventivas
-Inmunización (Vacuna) para Virus Respiratorio Sincitial
Servicios de Visión Pediátrica
Visión Pediátrica (Lentes de Correción Visual o marcos (frames) para Lentes de
Corrección Visual)
Otros Servicios Cubiertos
Examen de Refracción (adultos y niños)
Ambulancia Aerea en Puerto Rico
Servicios de emergencia en EU
Servicios en los Estados Unidos de América de casos donde se requiera equipo,
tratmiento y facilidades no disponibles en Puerto Rico
Beneficio de Cirugía Bariátrica para el Tratamiento de Obesidad Mórbida
Procedimiento de Cirugía Bariátrica
Programas Inclido como Parte de sus Beneficios
Nutricionista
Cubierta Dental
-Diagnostico y Preventivo
-Mantenedores de Espacio