284-43-6010  <<  284-43-6020 >>   284-43-6040

WAC 284-43-6020

Definitions.

For the purpose of this subchapter:
(1) "Adjusted earned premium" means the amount of "earned premium" the "carrier" would have earned had the "carrier" charged current "premium rates" for all applicable "plans."
(2) "Annualized earned premium" means the "earned premium" that would be earned in a twelve-month period if earned at the same rate as during the applicable period.
(3) "Anticipated loss ratio" means the "projected incurred claims" divided by the "projected earned premium."
(4) "Base rate" means the "premium" for a specific "plan," expressed as a monthly amount per "covered person or subscriber," prior to any adjustments for geographic area, age, family size, wellness activities, tenure, or any other factors as may be allowed.
(5) "Capitation expenses" means the amount paid to a provider or facility on a per "covered person" basis, or as part of risk-sharing provisions, for the coverage of specified health care services.
(6) "Carrier" means a health care service contractor or health maintenance organization.
(7) "Certificate" means the statement of coverage document furnished "subscribers" covered under a "group contract."
(8) "Claim reserves" means the "claims" that have been reported but not paid plus the "claims" that have not been reported but may be reasonably expected.
(9) "Claims" means the cost to the "carrier" of health care services provided to a "covered person" or paid to or on behalf of the "covered person" in accordance with the terms of a "plan." This includes "capitation payments" or other similar payments made to providers or facilities for the purpose of paying for health care services for a "covered person."
(10) "Community rate" means the weighted average of all "premium rates" within a filing with the weights determined according to current enrollment.
(11) "Contract" means an agreement to provide health care services or pay health care costs for or on behalf of a "subscriber" or group of "subscribers" and such eligible dependents as may be included therein.
(12) "Contract form" means the prototype of a "contract" and any associated riders and endorsements filed with the commissioner by a health care service contractor or health maintenance organization.
(13) "Contribution to surplus, contingency charges, or risk charges" means the portion of the "projected earned premium" not associated directly with "claims" or "expenses."
(14) "Covered person" or "enrollee" has the same meaning as that contained in RCW 48.43.005.
(15) "Current community rate" means the weighted average of the "community rates" at the renewal or initial effective dates of each plan for the year immediately preceding the renewal period, with weights determined according to current enrollment.
(16) "Current enrollment" means the monthly average number and demographic makeup of the "covered persons" for the applicable contracts during the most recent twelve months for which information is available to the carrier.
(17) "Earned premium" means the "premium" plus any rate credits or recoupments, applicable to an accounting period whether received before, during, or after such period.
(18) "Expenses" means costs that include but are not limited to the following:
(a) Claim adjudication costs;
(b) Utilization management costs if distinguishable from "claims";
(c) Home office and field overhead;
(d) Acquisition and selling costs;
(e) Taxes; and
(f) All other costs except "claims."
(19) "Experience period" means the most recent twelve-month period from which the carrier accumulates the data to support a filing.
(20) "Extraordinary expenses" means "expenses" resulting from occurrences atypical of the normal business activities of the "carrier" that are not expected to recur regularly in the near future.
(21) "Grandfathered" has the same meaning as that contained in RCW 48.43.005.
(22) "Group contract" or "group plan" means an agreement issued to an employer, corporation, labor union, association, trust, or other organization to provide health care services to employees or members of such entities and the dependents of such employees or members.
(23) "Incurred claims" means "claims" paid during the applicable period plus the "claim reserves" as of the end of the applicable period minus the "claim reserves" as of the beginning of the applicable period. Alternatively, for the purpose of providing monthly data or trend analysis, "incurred claims" may be defined as the current best estimate of the "claims" for services provided during the applicable period.
(24) "Individual contract" means a "contract" issued to and covering an individual. An "individual contract" may include dependents.
(25) "Investment earnings" means the income, dividends, and realized capital gains earned on an asset.
(26) "Loss ratio" means "incurred claims" as a percentage of "earned premiums" before any deductions.
(27) "Medical care component of the consumer price index for all urban consumers" means the similarly named figure published monthly by the United States Bureau of Labor Statistics.
(28) "Net worth or reserves and unassigned funds" means the excess of assets over liabilities on a statutory basis.
(29) "Plan" means a "contract" that is a health benefit plan as defined in RCW 48.43.005 or a "contract" for limited health care services as defined in RCW 48.44.035.
(30) "Premium" has the same meaning as that contained in RCW 48.43.005.
(31) "Premium rate" means the "premium" per "subscriber" or "covered person" obtained by adjusting the "base rate" for geographic area, family size, age, wellness activities, or any other factors as may be allowed.
(32) "Projected earned premium" means the "earned premium" that would be derived from applying the proposed "premium rates" to the current enrollment.
(33) "Projected incurred claims" means the estimate of "incurred claims" for the rate renewal period based on the current enrollment.
(34) "Proposed community rate" means the weighted average of the "community rates" at the renewal dates of each plan for the renewal period, with weights determined according to current enrollment.
(35) "Provider" has the same meaning as that contained in RCW 48.43.005.
(36) "Rate renewal period" means the period for which the proposed "premium rates" are intended to remain in effect.
(37) "Rate schedule" means the schedule of all "base rates" for "plans" included in the filing.
(38) "Requested increase in the community rate" means the amount, expressed as a percentage, by which the "proposed community rate" exceeds the "current community rate."
(39) "Service type" means the category of service for which "claims" are paid, such as hospital, professional, dental, prescription drug, or other.
(40) "Small group contracts" or "small group plans" means the class of "group contracts" issued to "small employers," as that term is defined in RCW 48.43.005.
(41) "Staffing data" means statistics on the number of providers and associated compensation required to provide a fixed number of services or provide services to a fixed number of "covered persons."
(42) "Stand-alone dental plan" means coverage for a set of benefits limited to oral care including, but not necessarily limited to, pediatric oral care.
(43) "Stand-alone vision plan" means coverage for a set of benefits limited to vision care including, but not necessarily limited to, materials.
(44) "Subscriber" means a person on whose behalf a "contract" or "certificate" is issued.
(45) "Unit cost data" means statistics on the cost per health care service provided to a "covered person."
(46) "Utilization data" means statistics on the number of services used by a fixed number of "covered persons" over a fixed length of time.
[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), § 284-43-6020, filed 11/4/16, effective 12/5/16. WSR 16-01-081, recodified as § 284-43-6020, 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), § 284-43-910, 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), § 284-43-910, 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), § 284-43-910, filed 1/23/98, effective 3/1/98.]
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