284-43-6640  <<  284-43-6660 >>   284-43-6680

Summary for individual and small group contract filings.

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:
 
[Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, and 2016 c 156. WSR 16-23-019 (Matter No. R 2016-06), recodified as § 284-43-6660, filed 11/4/16, effective 12/5/16. WSR 16-01-081, recodified as § 284-43-6160, filed 12/14/15, effective 12/14/15. Statutory Authority: RCW 48.02.060, 48.18.110, 48.44.020, 48.44.050, 48.46.060, 48.46.200. WSR 08-20-071 (Matter No. R 2008-08), § 284-43-945, filed 9/25/08, effective 10/26/08. Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200. WSR 05-07-006 (Matter No. R 2004-05), § 284-43-945, filed 3/3/05, effective 4/3/05. Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064 and 48.46.066. WSR 98-04-011 (Matter No. R 97-2), § 284-43-945, filed 1/23/98, effective 3/1/98.]
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