2006 Kentucky Revised Statutes - .095 Insurer issuing health benefit plan must file rates and charges -- Executive director\'s approval -- Policy forms -- Administrative regulations -- Hearing.

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304.17A-095 Insurer issuing health benefit plan must file rates and charges -- Executive director's approval -- Policy forms -- Administrative regulations -- Hearing. (1) (a) Notwithstanding any other provisions of this chapter to the contrary, each insurer that issues, delivers, or renews any health benefit plan to any market segment other than a large group shall, before use thereof, file with the executive director its rates, fees, dues, and other charges paid by insureds, members, enrollees, or subscribers. The insurer shall also submit a copy of the filing to the Attorney General and shall comply with the provisions of this section. The insurer shall adhere to its rates, fees, dues, and other charges as filed with the executive director. The insurer shall submit a new filing to reflect any material change to the previously filed and approved rate filing. For all other changes, the insurer shall submit an amendment to a previously approved rate filing. (b) Notwithstanding any other provisions of this chapter to the contrary, each insurer that issues, delivers, or renews any health benefit plan to a large group as defined in KRS 304.17A-005 shall file the rating methodology with the executive director and shall submit a copy of the filing to the Attorney General. (2) (a) A rate filing under this section may be used by the insurer on and after the date of filing with the executive director prior to approval by the executive director. A rate filing shall be approved or disapproved by the executive director within sixty (60) days after the date of filing. Should sixty (60) days expire after the executive director receives the filing before approval or disapproval of the filing, the filing shall be deemed approved. (b) In the circumstances of a filing that has been deemed approved or has been disapproved under paragraph (a) of this subsection, the executive director shall have the authority to order a retroactive reduction of rates to a reasonable rate if the executive director subsequently determines that the filing contained misrepresentations or was based on fraudulent information, and if after applying the factors in subsection (3) of this section the executive director determines that the rates were unreasonable. If the executive director seeks to order a retroactive reduction of rates and more than one (1) year has passed since the date of the filing, the executive director shall consider the reasonableness of the rate over the entire period during which the filing has been in effect. (3) In approving or disapproving a filing under this section, the executive director shall consider: (a) Whether the benefits provided are reasonable in relation to the premium or fee charged; (b) Whether the fees paid to providers for the covered services are reasonable in relation to the premium or fee charged; Page 1 of 5

(c) Previous premium rates or fees for the policies or contracts to which the filing applies; (d) The effect of the rate or rate increase on policyholders, enrollees, and subscribers; (e) Whether the rates, fees, dues, or other charges are excessive, inadequate, or unfairly discriminatory; (f) The effect on the rates of any assessment made under KRS 304.17B-021; and (g) Other factors as deemed relevant by the executive director. (4) The rates for each policyholder shall be guaranteed for twelve (12) months at the rate in effect on the date of issue or date of renewal. (5) At any time the executive director, after a public hearing for which at least thirty (30) days' notice has been given, may withdraw approval of rates or fees previously approved under this section and may order an appropriate refund or future premium credit to policyholders, enrollees, and subscribers if the executive director determines that the rates or fees previously approved are in violation of this chapter. (6) Notwithstanding subsection (2) of this section, premium rates may be used upon filing with the office of a policy form not previously used if the filing is accompanied by the policy form filing and a minimum loss ratio guarantee. Insurers may use the filing procedure specified in this subsection only if the affected policy forms disclose the benefit of a minimum loss ratio guarantee. An insurer may not elect to use the filing procedure in this subsection for a policy form that does not contain the minimum loss ratio guarantee. If an insurer elects to use the filing procedure in this subsection for a policy form or forms, the insurer shall not use a filing of premium rates that does not provide a minimum loss ratio guarantee for that policy form or forms. (a) The minimum loss ratio shall be in writing and shall contain at least the following: 1. An actuarial memorandum specifying the expected loss ratio that complies with the standards as set forth in this subsection; 2. A statement certifying that all rates, fees, dues, and other charges are not excessive, inadequate, or unfairly discriminatory; 3. Detailed experience information concerning the policy forms; 4. A step-by-step description of the process used to develop the experience loss ratio, including demonstration with supporting data; 5. A guarantee of a specific lifetime minimum loss ratio, that shall be greater than or equal to the following, taking into consideration adjustments for duration as set forth in administrative regulations promulgated by the executive director: a. Sixty-five percent (65%) for policies issued to individuals or for certificates issued to members of an association that does not offer coverage to small employers; Page 2 of 5

b. Seventy percent (70%) for policies issued to small groups of two (2) to ten (10) employees or for certificates issued to members of an association that offers coverage to small employers; and c. Seventy-five percent (75%) for policies issued to small groups of eleven (11) to fifty (50) employees; 6. A guarantee that the actual Kentucky loss ratio for the calendar year in which the new rates take effect, and for each year thereafter until new rates are filed, will meet or exceed the minimum loss ratio standards referred to in subparagraph 5. of this paragraph, adjusted for duration; 7. A guarantee that the actual Kentucky lifetime loss ratio shall meet or exceed the minimum loss ratio standards referred to in subparagraph 5. of this paragraph; and 8. If the annual earned premium volume in Kentucky under the particular policy form is less than two million five hundred thousand dollars ($2,500,000), the minimum loss ratio guarantee shall be based partially on the Kentucky earned premium and other credibility factors as specified by the executive director. (b) The actual Kentucky minimum loss ratio results for each year at issue shall be independently audited at the insurer's expense and the audit shall be filed with the executive director not later than one hundred twenty (120) days after the end of the year at issue. The audit shall demonstrate the calculation of the actual Kentucky loss ratio in a manner prescribed as set forth in administrative regulations promulgated by the executive director. (c) The insurer shall refund premiums in the amount necessary to bring the actual loss ratio up to the guaranteed minimum loss ratio. (d) A Kentucky policyholder affected by the guaranteed minimum loss ratio shall receive a portion of the premium refund relative to the premium paid by the policyholder. The refund shall be made to all Kentucky policyholders insured under the applicable policy form during the year at issue if the refund would equal ten dollars ($10) or more per policy. The refund shall include statutory interest from July 1 of the year at issue until the date of payment. Payment shall be made not later than one hundred eighty (180) days after the end of the year at issue. (e) Premium refunds of less than ten dollars ($10) per insured shall be aggregated by the insurer and paid to the Kentucky State Treasury. (f) None of the provisions of subsections (2) and (3) of this section shall apply if premium rates are filed with the office and accompanied by a minimum loss ratio guarantee that meets the requirements of this subsection. Such filings shall be deemed approved. Each insurer paying a risk assessment under KRS 304.17B-021 may include the amount of the assessment in establishing premium rates filed with the executive director under this section. The insurer shall identify any assessment allocated. Page 3 of 5

(g) The policy form filing of an insurer using the filing procedure with a minimum loss ratio guarantee will disclose to the enrollee, member, or subscriber as prescribed by the executive director an explanation of the lifetime loss ratio guarantee, and the actual loss ratio, and any adjustments for duration. (h) The insurer who elects to use the filing procedure with a minimum loss ratio guarantee shall notify all policyholders of the refund calculation, the result of the refund calculation, the percent of premium on an aggregate basis to be refunded if any, any amount of the refund attributed to the payment of interests, and an explanation of amounts less than ten dollars ($10). (i) Notwithstanding the provisions of this subsection, an insurer may amend the policy forms used before March 31, 2005, or may amend the minimum loss ratio guarantee on policy forms filed with the office and used by the insurer prior to March 31, 2005, to provide for a minimum loss ratio guarantee allowed under this subsection for policies issued, delivered, or renewed on or after March 31, 2005. (7) The executive director may by administrative regulation prescribe any additional information related to rates, fees, dues, and other charges as they relate to the factors set out in subsection (3) of this section that he or she deems necessary and relevant to be included in the filings and the form of the filings required by this section. When determining a loss ratio for the purposes of loss ratio guarantee, the insurer shall divide the total of the claims incurred, plus preferred provider organization expenses, case management and utilization review expenses, plus reinsurance premiums less reinsurance recoveries by the premiums earned less state and local premium taxes less other assessments. For purposes of determining the loss ratio for any loss ratio guarantee pursuant to this section, the executive director may examine the insurer's expenses for preferred provider organization, case management, utilization review, and reinsurance used by the insurer in calculating the loss ratio guarantee for reasonableness. Only those expenses found to be reasonable by the executive director may be used by the insurer for determining the loss ratio for purposes of any loss ratio guarantee. (8) (a) The executive director shall hold a hearing upon written request by the Attorney General. The written request shall be based upon one (1) or more of the reasons set out in subsection (3) of this section and shall state the applicable reasons. (b) An insurer may request a hearing, pursuant to KRS 304.2-310, with regard to any action taken by the executive director under this section as to the disapproval of rates or an order of a retroactive reduction of rates. (c) The hearing shall be a public hearing conducted in accordance with KRS 304.2-310. Effective: March 31, 2005 History: Amended 2005 Ky. Acts ch. 183, sec. 2, effective March 31, 2005. -- Amended 2004 Ky. Acts ch. 59, sec. 3, effective July 13, 2004. -- Amended 2002 Ky. Acts ch. 351, sec. 3, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 476, Page 4 of 5

sec. 25, effective January 1, 2001; and 2000 Ky. Acts ch. 521, sec. 14, effective July 14, 2000. -- Amended 1998 Ky. Acts ch. 496, sec. 9, effective April 10, 1998. -- Created 1996 Ky. Acts ch. 371, sec. 16, effective July 15, 1996. Legislative Research Commission Note (6/20/2005). 2005 Ky. Acts chs. 11, 85, 95, 97, 98, 99, 123, and 181 instruct the Reviser of Statutes to correct statutory references to agencies and officers whose names have been changed in 2005 legislation confirming the reorganization of the executive branch. Such a correction has been made in this section. Page 5 of 5
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