 |
Virginia Administrative Code (Last Updated: January 10, 2017) |
 |
Title 14. Insurance |
|
Agency 5. State Corporation Commission, Bureau of Insurance |
|
Chapter 130. Rules Governing the Filing of Rates for Individual and Certain Group Accidentand Sickness Insurance Policy Forms |
Section 81. Risk pools and index rate
-
A. A health insurance issuer shall consider the claims experience of all enrollees in all health benefit plans, other than grandfathered plans and student health insurance coverage, in the individual market to be members of a single risk pool.
B. A health insurance issuer shall consider the claims experience of all enrollees in all health plans, other than grandfathered plans, in the small group market to be members of a single risk pool.
C. Each plan year or policy year, as applicable, a health insurance issuer shall establish an index rate based on the total combined claims costs for providing essential health benefits within the single risk pool of the individual or small group market. 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 health insurance issuer's plans shall use the applicable index rate, as adjusted in accordance with subsection D of this section.
D. A health insurance issuer 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:
1. Cost-sharing design of the plan.
2. The plan's provider network, delivery system characteristics, and utilization management practices.
3. The benefits provided under the plan that are in addition to the essential health benefits. These additional benefits shall be pooled with similar benefits within a single risk pool and the claims experience from those benefits shall be utilized to determine rate variations for plans that offer those benefits in addition to essential health benefits.
4. Administrative costs, excluding health benefit exchange user fees.
5. With respect to catastrophic plans, the expected impact of the specific eligibility categories for those plans.
Historical Notes
Derived from Volume 29, Issue 20, eff. July 1, 2013; amended, Virginia Register Volume 32, Issue 09, eff. January 1, 2016.