WAC 284-43-6660. Summary for individual and small group contract filings

INDIVIDUAL AND SMALL GROUP FILING SUMMARY Carrier Name Address Carrier Identification Number Carrier Name Address Carrier Identification Number Rate Renewal Period: From To Date Submitted: Rate Renewal Period: From To Date Submitted: Proposed Rate Summary Current community rate per month Proposed community rate per month Percentage change % Portion of carrier's total enrollment affected % Portion of carrier's total premium revenue affected % Current community rate per month Proposed community rate per month Percentage change % Portion of carrier's total enrollment affected % Portion of carrier's total premium revenue affected % Components of Proposed Community Rate Dollars Per Month % of Total a) Claims b) Expenses c) Contribution to surplus, contingency charges, or risk charges d) Investment earnings e) Total (a + b + c - d) Dollars Per Month % of Total a) Claims b) Expenses c) Contribution to surplus, contingency charges, or risk charges d) Investment earnings e) Total (a + b + c - d) Summary of Pooled Experience Experience Period First Prior Period Second Prior Period From To From To From To Member Months Earned Premium Paid Claims Beginning Claim Reserve Ending Claim Reserve Incurred Claims Expenses Gain/Loss Loss Ratio Percentage Experience Period First Prior Period Second Prior Period From To From To From To Member Months Earned Premium Paid Claims Beginning Claim Reserve Ending Claim Reserve Incurred Claims Expenses Gain/Loss Loss Ratio Percentage General Information 1. Trend Factor Summary 1. Trend Factor Summary Type of Service Annual Trend Assumed Portion of Claim Dollars Hospital % % Professional % % Prescription Drugs % % Dental % % Other % % Type of Service Annual Trend Assumed Portion of Claim Dollars Hospital % % Professional % % Prescription Drugs % % Dental % % Other % % 2. List the effective date and the rate of increase for all rate changes in the past three rate periods. 1) 2) 3) Date % Date % Date % 3. Since the previous filing, have any changes been made to the factors or methodology for adjusting base rates? Geographic Area □ Yes □ No Family Size □ Yes □ No Age □ Yes □ No Wellness Activities □ Yes □ No Other (specify) □ Yes □ No 4. Attach a table showing the base rate for each plan affected by this filing. 5. Attach comments or additional information. 6. Preparer's Information Name: Title: Telephone Number: 2. List the effective date and the rate of increase for all rate changes in the past three rate periods. 1) 2) 3) Date % Date % Date % 3. Since the previous filing, have any changes been made to the factors or methodology for adjusting base rates? Geographic Area □ Yes □ No Family Size □ Yes □ No Age □ Yes □ No Wellness Activities □ Yes □ No Other (specify) □ Yes □ No 4. Attach a table showing the base rate for each plan affected by this filing. 5. Attach comments or additional information. 6. Preparer's Information Name: Title: Telephone Number: