PDFWAC 284-43-6660
Summary for individual and small group contract filings.
INDIVIDUAL AND SMALL GROUP FILING SUMMARY
Carrier Name | |
Address | |
Carrier Identification Number | |
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 | % |
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) |
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 |
General Information
1. Trend Factor Summary |
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: | ||||||||
[Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, and 2016 c 156. WSR 16-23-019 (Matter No. R 2016-06), recodified as § 284-43-6660, filed 11/4/16, effective 12/5/16. WSR 16-01-081, recodified as § 284-43-6160, filed 12/14/15, effective 12/14/15. Statutory Authority: RCW 48.02.060, 48.18.110, 48.44.020, 48.44.050, 48.46.060, 48.46.200. WSR 08-20-071 (Matter No. R 2008-08), § 284-43-945, filed 9/25/08, effective 10/26/08. Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200. WSR 05-07-006 (Matter No. R 2004-05), § 284-43-945, filed 3/3/05, effective 4/3/05. Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064 and 48.46.066. WSR 98-04-011 (Matter No. R 97-2), § 284-43-945, filed 1/23/98, effective 3/1/98.]