Wash. Admin. Code § 284-43-6660
Current through Register Vol. 24-12, June 15, 2024
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
| 1. Trend Factor Summary | ||||||||
| 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: _________________ | ||||||||
Wash. Admin. Code § 284-43-6660