N.J. Admin. Code § 11:10-1.12

Current through Register Vol. 56, No. 23, December 2, 2024

Section 11:10-1.12 - Schedule of premiums

(a) A DPO shall file a schedule of premiums at least annually. Every new or revised schedule of premiums shall be filed with the Commissioner at least 60 days prior to the effective date of coverage using that schedule of premiums. The Commissioner may disapprove a schedule of premiums at any time if the premiums provided thereunder are excessive, inadequate, or unfairly discriminatory, or if the filing does not substantially comply with the requirements of this section. A DPO shall not use a schedule of premiums which has not been filed, or which has been disapproved by the Commissioner.

(b) Every filing shall include all information to determine premiums, including the following:

1. A plan schedule and rate manual containing the following:

i. The rating period for which the filing is effective;

ii. A description of the plan of benefits, including deductibles, copays, and limits for each type of covered service;

iii. The basic premium or rate for each plan of benefits;

iv. The coverage period, if any, for which guaranteed premiums are guaranteed;

v. The numerical value of any classification factors used in the determination of premiums for a group, including age, gender, location, industry, prior coverage, and group size;

vi. A description of the rating methodology which will allow the determination of the premium for any group from group-specific information and the information in (b)1i, ii and iv above;

vii. A detailed example calculation of the premium for a sample group, giving all necessary group-specific information and using the methodology described in (b)1v above;

viii. An example that includes a sample of the rate proposal format using the sample premiums; and

ix. For a revision filing, the date and effective period of the filing that is being revised;

2. An actuarial memorandum containing the methods and assumptions used in determining the premiums, including:

i. Recent claim cost experience and the source of that experience. This shall include the actual experience of the DPO, unless such experience is inadequate for rate determination;

ii. Trend assumptions for claim costs and the source of the trend assumptions;

iii. The portion of the premium to be used for the direct provision of professional dental services to enrollees, including capitation and other compensation (11:10-1.9(b) and (d) );

iv. The portion of the premium used for retention (11:10-1.9(d) ) exclusive of profit and surplus charges (see (b)2v below);

v. The portion of the premium used for profits, contingencies, or contributions to surplus; and

vi. For a filing of revised premiums, the percentage increase in rates from the previous filing; and

3. An actuarial certification that the premiums are intended to meet the requirements of 17:48D-14 and 11:10-1.9(a)1.

(c) A single case rate filing shall contain, in place of the rate manual and plan schedule, a statement of the rates and a comparison of those rates to the rates that would be attained by the rate methodology described in (b)1v above. The actuarial memorandum shall discuss the basis for the rates in the single case filing, including competitive considerations or producer concessions. The actuarial certification shall state that the premiums are not discriminatory in violation of N.J.S.A. 17B:30-12d.9 and that the premiums do not include an illegal rebate or inducement in violation of 17B:30-13.

(d) All actuarial memoranda and actuarial certifications shall be deemed to contain proprietary and confidential information.

(e) A schedule of premiums for a supplemental dental plan is also subject to (a) through (d) above. In determining whether such premiums comply with (a) through (d) above, the Department shall consider whether the premiums for a supplemental dental plan are proportionately equivalent to the premiums for a dental plan providing greater benefits. For example, the premium for a supplemental dental plan covering 20 percent of dental expenses must be no more than one-fifth of the premium for a plan covering 100 percent of these dental expenses.

(f) Rate filings shall be submitted to:

DPO Rate Filings, Life & Health Actuarial

New Jersey Dept. of Banking and Insurance

PO Box 325

20 West State Street

Trenton NJ 08625

N.J. Admin. Code § 11:10-1.12

Amended by R.1994 d.200, effective 4/18/1994.
See: 26 N.J.R. 738(a), 26 N.J.R. 1661(a).
Amended by R.2011 d.227, effective 9/6/2011.
See: 43 N.J.R. 124(a), 43 N.J.R. 2347(a).
Section was "Schedule of charges". Rewrote the section.