North Carolina Administrative Code (Last Updated: November 13, 2014) |
TITLE 11. INSURANCE |
CHAPTER 16. ACTUARIAL SERVICES DIVISION |
11 NCAC 16 .0604. INITIAL HMO RATE FILING DATA REQUIREMENTS AND STANDARDS
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(a) All initial HMO rate filings shall include, in addition to the data required by 11 NCAC 16 .0603, the following data:
(1) A comparison of the rates to other HMO rates with the same effective date in North Carolina for similar benefit plans.
(2) A completed diskette, provided by the Actuarial Services Division of the Department, containing a three-year financial projection that details total membership, revenues and expenses, and that includes a statement of cash flow, a balance sheet, and a statement of working capital and net worth.
(b) All initial HMO rate filings shall use in the rate development a total retention loading of:
(1) no greater than 25.0% of the total premium rate for full-service HMO products issued on a group basis;
(2) no greater than 35.0% of the total premium rate for single-service HMO products issued on a group basis;
(3) no greater than 35.0% of the total premium rate for full-service HMO products issued on an individual basis;
(4) no greater than 45.0% of the total premium rate for single-service HMO products issued on an individual basis.
(c) If an HMO uses a total retention loading which is less than the maximum limit cited in Paragraph (b) of this Rule minus 15.0%, then the following supporting documentation shall be included in the filing:
(1) a listing of each of the specific components which make up the total retention loading expressed as a percentage of premium;
(2) a brief description of the methodology employed to obtain each of the components which make up the total retention loading;
(3) a brief explanation as to why any of the components which make up the total retention loading have changed and a statement of opinion from an officer of the HMO that these changes are permanent in nature;
(4) a brief, summary description of the impact of any special fee negotiations or contract arrangements which affect the premium rates; identification of specific hospitals or physician groups is not required;
(5) a comparison of the rates to other HMO rates with similar benefit plans.
(d) All HMO's must project a positive net income after taxes in each of the last 12 months of the three year financial projection.
History Note: Authority G.S. 58-67-10(d)(1); 58-67-50(b); 58-67-150;
Eff. April 1, 1995.