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
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.]