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304.17A-095 Insurer issuing health benefit plan must file rates and charges --
Commissioner's approval -- Policy forms -- Administrative regulations -- <br>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 <br>segment other than a large group shall, before use thereof, file with the <br>commissioner its rates, fees, dues, and other charges paid by insureds, <br>members, enrollees, or subscribers. The insurer shall also submit a copy of the <br>filing to the Attorney General and shall comply with the provisions of this <br>section. The insurer shall adhere to its rates, fees, dues, and other charges as <br>filed with the commissioner. The insurer shall submit a new filing to reflect <br>any material change to the previously filed and approved rate filing. For all <br>other changes, the insurer shall submit an amendment to a previously <br>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 <br>as defined in KRS 304.17A-005 shall file the rating methodology with the <br>commissioner 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 commissioner prior to approval by the commissioner. A <br>rate filing shall be approved or disapproved by the commissioner within sixty <br>(60) days after the date of filing. Should sixty (60) days expire after the <br>commissioner receives the filing before approval or disapproval of the filing, <br>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 commissioner shall <br>have the authority to order a retroactive reduction of rates to a reasonable rate <br>if the commissioner subsequently determines that the filing contained <br>misrepresentations or was based on fraudulent information, and if after <br>applying the factors in subsection (3) of this section the commissioner <br>determines that the rates were unreasonable. If the commissioner seeks to <br>order a retroactive reduction of rates and more than one (1) year has passed <br>since the date of the filing, the commissioner shall consider the reasonableness <br>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 commissioner shall
consider: <br>(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;
(c) Previous premium rates or fees for the policies or contracts to which the filing
applies;
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(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 <br>(g) Other factors as deemed relevant by the commissioner.
(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 commissioner, after a public hearing for which at least thirty (30)
days' notice has been given, may withdraw approval of rates or fees previously <br>approved under this section and may order an appropriate refund or future premium <br>credit to policyholders, enrollees, and subscribers if the commissioner determines <br>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 department of a policy form not previously used if the filing is <br>accompanied by the policy form filing and a minimum loss ratio guarantee. Insurers <br>may use the filing procedure specified in this subsection only if the affected policy <br>forms disclose the benefit of a minimum loss ratio guarantee. An insurer may not <br>elect to use the filing procedure in this subsection for a policy form that does not <br>contain the minimum loss ratio guarantee. If an insurer elects to use the filing <br>procedure in this subsection for a policy form or forms, the insurer shall not use a <br>filing of premium rates that does not provide a minimum loss ratio guarantee for <br>that policy form or forms. <br>(a) The minimum loss ratio shall be in writing and shall contain at least the
following: <br>1.
An actuarial memorandum specifying the expected loss ratio that <br>complies with the standards as set forth in this subsection;
2.
A statement certifying that all rates, fees, dues, and other charges are not <br>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 <br>loss ratio, including demonstration with supporting data;
5.
A guarantee of a specific lifetime minimum loss ratio, that shall be <br>greater than or equal to the following, taking into consideration <br>adjustments for duration as set forth in administrative regulations <br>promulgated by the commissioner: <br>a.
Sixty-five percent (65%) for policies issued to individuals or for <br>certificates issued to members of an association that does not offer <br>coverage to small employers;
b.
Seventy percent (70%) for policies issued to small groups of two <br>(2) to ten (10) employees or for certificates issued to members of <br>an association that offers coverage to small employers; and
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c.
Seventy-five percent (75%) for policies issued to small groups of <br>eleven (11) to fifty (50) employees;
6.
A guarantee that the actual Kentucky loss ratio for the calendar year in <br>which the new rates take effect, and for each year thereafter until new <br>rates are filed, will meet or exceed the minimum loss ratio standards <br>referred to in subparagraph 5. of this paragraph, adjusted for duration;
7.
A guarantee that the actual Kentucky lifetime loss ratio shall meet or <br>exceed the minimum loss ratio standards referred to in subparagraph 5. <br>of this paragraph; and
8.
If the annual earned premium volume in Kentucky under the particular <br>policy form is less than two million five hundred thousand dollars <br>($2,500,000), the minimum loss ratio guarantee shall be based partially <br>on the Kentucky earned premium and other credibility factors as <br>specified by the commissioner.
(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 <br>the commissioner not later than one hundred twenty (120) days after the end <br>of the year at issue. The audit shall demonstrate the calculation of the actual <br>Kentucky loss ratio in a manner prescribed as set forth in administrative <br>regulations promulgated by the commissioner.
(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 <br>policyholder. The refund shall be made to all Kentucky policyholders insured <br>under the applicable policy form during the year at issue if the refund would <br>equal ten dollars ($10) or more per policy. The refund shall include statutory <br>interest from July 1 of the year at issue until the date of payment. Payment <br>shall be made not later than one hundred eighty (180) days after the end of the <br>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 department and accompanied by a minimum <br>loss ratio guarantee that meets the requirements of this subsection. Such <br>filings shall be deemed approved. Each insurer paying a risk assessment under <br>KRS 304.17B-021 may include the amount of the assessment in establishing <br>premium rates filed with the commissioner under this section. The insurer <br>shall identify any assessment allocated.
(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 <br>subscriber as prescribed by the commissioner an explanation of the lifetime
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loss ratio guarantee, and the actual loss ratio, and any adjustments for <br>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 <br>the refund calculation, the percent of premium on an aggregate basis to be <br>refunded if any, any amount of the refund attributed to the payment of <br>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 <br>ratio guarantee on policy forms filed with the department and used by the <br>insurer prior to March 31, 2005, to provide for a minimum loss ratio guarantee <br>allowed under this subsection for policies issued, delivered, or renewed on or <br>after March 31, 2005.
(7) The commissioner may by administrative regulation prescribe any additional
information related to rates, fees, dues, and other charges as they relate to the <br>factors set out in subsection (3) of this section that he or she deems necessary and <br>relevant to be included in the filings and the form of the filings required by this <br>section. When determining a loss ratio for the purposes of loss ratio guarantee, the <br>insurer shall divide the total of the claims incurred, plus preferred provider <br>organization expenses, case management and utilization review expenses, plus <br>reinsurance premiums less reinsurance recoveries by the premiums earned less state <br>and local premium taxes less other assessments. For purposes of determining the <br>loss ratio for any loss ratio guarantee pursuant to this section, the commissioner <br>may examine the insurer's expenses for preferred provider organization, case <br>management, utilization review, and reinsurance used by the insurer in calculating <br>the loss ratio guarantee for reasonableness. Only those expenses found to be <br>reasonable by the commissioner may be used by the insurer for determining the loss <br>ratio for purposes of any loss ratio guarantee.
(8) (a) The commissioner shall hold a hearing upon written request by the Attorney
General. The written request shall be based upon one (1) or more of the <br>reasons set out in subsection (3) of this section and shall state the applicable <br>reasons.
(b) An insurer may request a hearing, pursuant to KRS 304.2-310, with regard to
any action taken by the commissioner under this section as to the disapproval <br>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: July 15, 2010 <br>History: Amended 2010 Ky. Acts ch. 24, sec. 1212, effective July 15, 2010. --
Amended 2005 Ky. Acts ch. 183, sec. 2, effective March 31, 2005. -- Amended 2004 <br>Ky. Acts ch. 59, sec. 3, effective July 13, 2004. -- Amended 2002 Ky. Acts ch. 351, <br>sec. 3, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 476, sec. 25, effective <br>January 1, 2001; and 2000 Ky. Acts ch. 521, sec. 14, effective July 14, 2000. -- <br>Amended 1998 Ky. Acts ch. 496, sec. 9, effective April 10, 1998. -- Created 1996 <br>Ky. Acts ch. 371, sec. 16, effective July 15, 1996.
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