Statutes, codes, and regulations
Virginia Administrative Code
Title 14 - INSURANCEAgency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE
Chapter 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS
Section 14VAC5-130-81 - Risk pools and index rate

14 Va. Admin. Code § 5-130-81

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Current through Register Vol. 40, No. 22, June 17, 2024
Section 14VAC5-130-81 - Risk pools and index rate
A. This section shall only apply to individual or small employer group health insurance coverage, except for grandfathered plans and student health insurance coverage.
B. An insurer shall consider the claims experience of all individual health insurance coverage members, other than those in grandfathered plans and student health insurance coverage, to be members of a single risk pool.
C. An insurer shall consider the claims experience of all small employer group health insurance coverage members, other than those in grandfathered plans, to be members of a single risk pool.
D. Each plan year or policy year, as applicable, an insurer shall establish an index rate based on the total combined claims costs for providing essential health benefits within the single risk pool . The index rate may be adjusted on a market-wide basis based on the total expected market-wide payments and charges under the risk adjustment and reinsurance programs in this Commonwealth and the health benefit exchange user fees. The premium rate for all of the insurer's plans shall use the applicable index rate, as adjusted in accordance with subsection E of this section.
E. An insurer may vary premium rates for a particular plan from its index rate for a relevant state market based only on the following actuarially justified plan-specific factors in accordance with 45 CFR 156.80(d)(2):
1. Actuarial value and cost-sharing design of the plan.
2. The plan's provider network, delivery system characteristics, and utilization management practices.
3. Benefits provided under the plan that are in addition to the essential health benefits.
4. Administrative costs, excluding health benefit exchange user fees.
5. Only catastrophic plans may be adjusted for the expected impact of the specific eligibility categories for those plans.

14 Va. Admin. Code § 5-130-81

Derived from Virginia Register Volume 29, Issue 20, eff. July 1, 2013; Amended, Virginia Register Volume 32, Issue 09, eff. 1/1/2016; Amended, Virginia Register Volume 36, Issue 05, eff. 1/1/2020.

Statutory Authority: §§ 12.1-13 and 38.2-223 of the Code of Virginia.