OAR 836-053-0473
Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans


(1)

Every insurer that offers a health benefit plan for small employers or an individual health benefit plan must file the information specified in section (2) of this rule when the insurer files with the director a schedule or table of premium rates for approval.

(2)

A schedule or table of base premium rates filed under section (1) of this rule must include sufficient information and data to allow the director to consider the factors set forth in ORS 743.018 (Filing of rates for life and health insurance)(4) and (5). The filing must include all of the following separately set forth and labeled as indicated:

(a)

A filing description labeled “Filing Description.” The filing description must:

(A)

Be submitted in the form of a cover letter;

(B)

Provide a summary of the reasons an insurer is requesting a rate change and the minimum and maximum rate impact to all groups or members affected by the rate change, including the anticipated change in number of enrollees if the proposed premium rate is approved;

(C)

Explain the rate change in a manner understandable to the average consumer; and

(D)

Include a description of any significant changes the insurer is making to the following:
(i)
Rating factor changes; and
(ii)
Benefit or administration changes.

(b)

Rate tables and factors labeled “Rate Tables and Factors.” The rate tables and factors must:

(A)

Include base and geographic average rate tables;

(B)

Identify factors used by the insurer in developing the rates;

(C)

Explain how the information is used in the development of rates;

(D)

Include a table of rating factors reflecting ages of employees and dependents and geographic area.

(E)

Include rate tier tables if base rates are not provided by rating tier;

(F)

Indicate whether the rate increases are the same for all policies;

(G)

Explain how the rate increases apply to different policies;

(H)

Provide the entire distribution of rate changes and the average of the highest and lowest rates resulting from the application of other rating factors;

(I)

Within the geographic average rate table, include family type, geographic area and the average of the highest and lowest rates resulting from the application of other rating factors;

(J)

Within the base rate table, include the base rates for each available plan and sufficient information for determination of rates for each health benefit plan, including but not limited to:
(i)
Each age bracket;
(ii)
Each geographic area;
(iii)
Each rate tier;
(iv)
Any other variable used to determine rates; and
(v)
If the rates vary more frequently than annually, separate rates for each effective date of change or sufficient information to permit the determination of the rates and the justification for the variation in the rates.

(K)

For a grandfathered small group health benefit plan, include the following factors if applied by the insurer:
(i)
Contribution;
(ii)
Level of participation;
(iii)Family composition;
(iv)
The level at which enrollees or dependents engage in health promotion, disease prevention or wellness programs;
(v)
Duration of coverage in force;
(vi)
Any adjustment to reflect expected claims experience; and
(vii)
Age.

(L)

For a grandfathered individual health benefit plan, include the following factors to the extent applied by the insurer:
(i)
Family composition; and
(ii)
Age.

(M)

For a nongrandfathered health benefit plan, include the following factors if applied by the insurer:
(i)
Tobacco usage; and
(ii)
The level at which enrollees or dependents engage in health promotion, disease prevention, or wellness programs.

(c)

An actuarial memorandum consistent with the requirements of both state and federal law labeled “Actuarial Memorandum.” The actuarial memorandum must include all of the following:

(A)

A description of the benefit plan and a quantification of any changes to the benefit plan as set forth in subsection (e) of this section;

(B)

A discussion of assumptions, factors, calculations, rate tables and any other information pertinent to the proposed rate, including an explanation of the impact of risk corridors, risk adjustment and state and federal reinsurance on the proposed rate;

(C)

A description of any changes in rating methodology supported by sufficient detail to permit the department to evaluate the effect on rates and the rationale for the change;

(D)

The range of rate impact to groups or members including the distribution of the impact on members;

(E)

A cross-reference of all supporting documentation in the filing in the form of an index and citations;

(F)

The dated signature of the qualified actuary or actuaries who reviewed and authorized the rate filing; and

(G)

The contact information of the filer.

(d)

A description of the development of the proposed rate change or base rate that is included as an exhibit to the filing and labeled “Exhibit 1: Development of Rate Change.” The development of rate change is the core of the rate filing and must:

(A)

Explain how the proposed rate or rate change was calculated using generally accepted actuarial rating principles for rating blocks of business;

(B)

Include actual or expected membership information;

(C)

Identify a proposed loss ratio for the rating period;

(D)

Include a rate renewal calculation that:
(i)
Begins with an assumed experience period of at least one year and ends within the immediately preceding year; or
(ii)
If more recent data is available, uses the one-year period that ends with the most recent period for which data is available.

(E)

Show adjustments to total premium earned during the experience period to yield premium adjusted to current rates;

(F)

Include a projection of premiums and claims for the period during which the proposed rates are to be effective; and

(G)

Provide a renewal projection using claims underlying the projection that reflect an assumed medical trend rate and other expected changes in claims cost, including but not limited to, the impact of benefit changes or provider reimbursement.

(e)

A description of changes to covered benefits or health benefit plan design that is included as an exhibit to the rate filing and labeled “Exhibit 2: Covered Benefit or Plan Design Changes.” The covered benefit or plan design changes must:

(A)

Explain all applicable benefit and administrative changes with a rating impact, including but not limited to:
(i)
Covered benefit level changes;
(ii)
Member cost-sharing changes;
(iii)
Elimination of plans;
(iv)
Implementation of new plan designs;
(v)
Provider network changes;
(vi)
New utilization or prior authorization programs;
(vii)
Changes to eligibility requirements; and
(viii)
Changes to exclusions.

(B)

Show any change in the plan offerings that impacts costs or coverage provided not otherwise provided pursuant to subsection (e)(A) of this section.

(f)

The average annual rate change included as an exhibit to the filing and labeled “Exhibit 3: Average Annual Rate Change.” The average annual rate change must:

(A)

Provide the average, maximum and minimum annual rate changes for each effective date in the filing;

(B)

Include a meaningful distribution of rate changes; and

(C)

Provide an estimate of contributing factors to the annual rate change.

(g)

Trend information and projection included as an exhibit to the filing and labeled “Exhibit 4: Trend Information and Projection.” The trend information and projection must:

(A)

Describe how the assumed future growth of medical claims (the medical trends rate) was developed based on generally accepted actuarial principles; and

(B)

At a minimum, include historical monthly average claim costs for the two years immediately preceding the period for which the proposed rate is to apply. If the carrier’s structure does not include claims cost, the carrier must submit this information based on allocated costs.

(h)

A statement of administrative expenses and premium retention included as an exhibit to the filing and labeled “Exhibit 5: Statement of Administrative Expenses and Premium Retention.” The statement of administrative expenses and premium retention must:

(A)

Include a completed chart displaying the five-year trend of administrative costs and enumerating the insurer’s administrative expenses detailed as follows:
(i)
Salaries;
(ii)
Rent;
(iii)
Advertising;
(iv)
General office expenses;
(v)
Third party administration expenses;
(vi)
Legal and other professional fees; and
(vii)
Travel and other administrative costs not accounted for under a category in subsections (h)(B)(i)–(vi) of this section.

(B)

Explain how the insurer allocates administrative expenses for the filed line of business;

(C)

Include a description of the amount retained by the insurer to cover all of the insurer’s non-claim costs including expected profit or contribution to surplus for a nonprofit entity reported on a percentage of premium and per member per month basis; and

(D)

Demonstrate the total premium retention for the filing, including total administrative expenses reported under subsection (h)(B) of this section, commissions, taxes, assessments and margin.
(i)
Plan relativities included as an exhibit to the filing and labeled “Exhibit 6: Plan Relativities.” Plan relativities must:

(A)

Explain the presentation of rates for each benefit plan;

(B)

Explain the methodology of how the benefit plan relativities were developed; and

(C)

Demonstrate the comparison and reasonableness of benefits and costs between plans.

(j)

Information about the insurer’s financial position included as an appendix to the filing and labeled “Appendix I: Insurer’s Financial Position.” The insurer’s financial position may reference documents filed with the department and available to the public, including the insurer’s annual statement. The insurer’s financial position must include:

(A)

Information about the insurer’s financial position including but not limited to the insurer’s:
(i)
Profitability;
(ii)
Surplus;
(iii)
Reserves; and
(iv)
Investment earnings.

(B)

An analysis, explanation and determination of whether the proposed change in the premium rate is necessary to maintain the insurer’s solvency or to maintain rate stability and prevent excessive rate increases in the future.

(k)

Changes in the insurer’s health care cost containment and quality improvement efforts included as an appendix to the filing and labeled “Appendix II: Cost Containment and Quality Improvement Efforts. The cost containment and quality improvement efforts must:

(A)

Explain any changes the insurer has made in its health care cost containment efforts and quality improvement efforts since the insurer’s last rate filing for the same category of health benefit plan;

(B)

Describe significant new health care cost containment initiatives and quality improvement efforts;

(C)

Include an estimate of the potential savings from the initiatives and efforts described in subsection (2(g)(B) of this section together with an estimate of the cost or savings for the projection period; and

(D)

Include information about whether the cost containment initiatives reduce costs by eliminating waste, improving efficiency, by improving health outcomes through incentives, by elimination or reduction of covered services or reduction in the fees paid to providers for services.

(l)

Information regarding prescription drug costs included as an appendix to the filing and labeled “Appendix III: Prescription Drug Costs.” This document must include, for drugs reimbursed by the insurer under both pharmacy and medical benefits for policies or certificates issued in this state and for the experience period covered in the filing, all of the following:
(A) The 25 most frequently prescribed drugs;
(B) The 25 most costly drugs. In determining this list, the insurer must consider total annual spending, including the net impact of any rebates or other price concessions if applicable;
(C) The 25 drugs that have caused the greatest increase in total plan spending from one year to the next. In determining this list, the insurer must consider the net impact on total plan spending of any rebates or other price concessions if applicable; and
(D) The impact of the costs of prescription drugs on premium rates, on a per member, per month basis, including the net impact of any rebates or other price concessions if applicable.

(m)

Certification of compliance labeled “Certification of Compliance.” The certification of compliance must:

(A)

Comply with OAR 836-010-0011 (Filing, Review of Rates and Forms); and

(B)

Certify that the filing complies with all applicable Oregon statutes, rules, product standards and filing requirements.

(n)

Third party filer’s letter of authorization labeled “Third Party Authorization.” If the filing is submitted by a person other than the insurer to which the filing applies, the filing must include a letter from the insurer that authorizes the third party to:

(A)

Submit the filing to the department;

(B)

Correspond with the department on matters pertaining to the rate filing; and

(C)

Act on the insurer’s behalf regarding all matters related to the filing.

(3)

Insurers offering individual and small group health benefit plans that spend less than 12 percent of total medical expenditures on payments for primary care must include with each health benefit plan rate filing a plan to increase spending on payments for primary care by at least one percentage point each year. Once an insurer has met the 12 percent benchmark for primary care spending, that fact must be disclosed with each health benefit plan rate filing including a disclosure of the current percentage of total medical expenditures on primary care. Insurers shall use the methodology outlined in the annual Primary Care Spending in Oregon report to calculate the percentage of primary care spending.

Source: Rule 836-053-0473 — Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-053-0473.

836–053–0000
Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53
836–053–0001
Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements
836–053–0002
Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements
836–053–0003
Prohibition of Exclusion Period for Pregnancy
836–053–0004
Compliance with Federal and State Law
836–053–0005
Prescription Drug Identification Cards
836–053–0007
Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements
836–053–0008
Essential Health Benefits for Plan Years 2014, 2015 and 2016
836–053–0009
Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016
836–053–0011
Standard Bronze Plan Health Savings Account Eligible Requirement
836–053–0012
Essential Health Benefits for Plan Years Beginning on and after January 1, 2017
836–053–0013
Oregon Standard Bronze and Silver Health Benefit Plans
836–053–0014
Standards and Process for Shortened Period of Market Prohibition
836–053–0015
Definition of Small Employer
836–053–0017
Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022
836–053–0019
Purpose
836–053–0021
Plans Offered to Oregon Small Employers
836–053–0030
Marketing of a Health Benefit Plan to Small Employers
836–053–0050
Trade Practices Relating to Small Employer Health Benefit Plans
836–053–0063
Rating for Nongrandfathered Small Group Plans
836–053–0065
Rating for Grandfathered Small Group Plans
836–053–0066
Rating for Transitional Health Benefit Plans Offered to Small Employers
836–053–0070
Multiple Employer Welfare Arrangements
836–053–0100
Work Related Injuries or Disease
836–053–0105
Coordination of Payment for Interim Medical Services
836–053–0211
Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan
836–053–0221
Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans
836–053–0230
Underwriting
836–053–0300
Purpose
836–053–0310
Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0350
836–053–0320
Annual Report Requirements for Network Adequacy
836–053–0330
Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements
836–053–0340
Factor-Based Evidence of Compliance with Network Adequacy Requirements
836–053–0350
Provider Directory Requirements for Network Adequacy
836–053–0410
Purpose
836–053–0415
Cancellation of an Individual Health Benefit Plan Coverage
836–053–0418
Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic
836–053–0431
Underwriting, Enrollment and Benefit Design
836–053–0435
Health Benefit Plan Coverage of Well-woman Preventive Care Services
836–053–0465
Rating for Individual Health Benefit Plans
836–053–0472
Statutory Authority and Implementation
836–053–0473
Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans
836–053–0474
Process For Rate Filing for Individual and Small Employer Health Benefit Plans
836–053–0475
Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan
836–053–0510
Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage
836–053–0600
Purpose
836–053–0605
Definitions for OAR 836-053-0600 to 836-053-0615
836–053–0610
Carrier Response to Request for Confidentiality
836–053–0615
Carrier Reporting Requirements
836–053–0825
Rescission of a Group Health Benefit Plan
836–053–0830
Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy
836–053–0835
Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy
836–053–0851
Purpose
836–053–0857
Definitions
836–053–0863
Notifications
836–053–0900
Purpose
836–053–0910
Rate Filing
836–053–1000
Statutory Authority and Implementation
836–053–1010
Insurer Policies
836–053–1020
Drug Formularies
836–053–1030
Written Information to Enrollees
836–053–1033
Cultural and Linguistic Appropriateness
836–053–1035
Summary of Benefits and Explanation of Coverage
836–053–1060
Definitions
836–053–1070
Reporting of Grievances
836–053–1080
Tracking Grievances
836–053–1090
Assistance in Filing Grievances
836–053–1100
Internal Appeals Process
836–053–1110
Notice of Complaint Filing with Director
836–053–1130
Annual Summary, Utilization Review
836–053–1140
Appeal and Utilization Review Determinations
836–053–1170
Annual Summary, Quality Assessment Activities
836–053–1180
Format and Instructions for Report Required by ORS 743.818
836–053–1190
Annual Summary, Uniform Indicators of Network Adequacy
836–053–1200
Prior Authorization Requirements for Health Benefit Plans
836–053–1203
Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans
836–053–1205
Uniform Prescription Drug Prior Authorization Request Form
836–053–1300
Purpose and Scope
836–053–1305
Definitions
836–053–1310
Contracting Requirements
836–053–1315
Performance Criteria
836–053–1317
Professional Qualifications
836–053–1320
Conflict of Interest
836–053–1325
Procedures for Conducting External Reviews
836–053–1330
Criteria and Considerations for External Review Determinations
836–053–1335
Procedures for Complaint Investigation
836–053–1337
Preliminary Review by Insurer
836–053–1340
Timelines and Notice for Dispute That is Not Expedited
836–053–1342
Timelines and Notice for Expedited Decision-Making
836–053–1345
Quality Assurance Mechanisms
836–053–1350
Ongoing Requirements for Independent Review Organizations
836–053–1355
Synopses
836–053–1360
External Review Reporting
836–053–1365
Fees for External Reviews
836–053–1400
Format and Instructions for Report Required by ORS 743.748
836–053–1403
Definitions of Coordinated Care and Case Management for Behavioral Health Care Services
836–053–1404
Definitions
836–053–1405
General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency
836–053–1407
Prohibited Exclusions
836–053–1408
Required Disclosures
836–053–1409
Definitions
836–053–1410
Procedures
836–053–1415
Instructions
836–053–1500
Purpose
836–053–1505
Definitions for OAR 836-053-1500 to 836-053-1510
836–053–1510
Prominent Carrier Reporting Requirements
836–053–1520
Purpose
836–053–1525
Definitions
836–053–1530
Reporting Requirements
836–053–1600
Purpose
836–053–1605
Definitions for 836-053-1600 to 836-053-1615
836–053–1610
Non-anesthesia-related claims
836–053–1615
Anesthesia-related claims
Last Updated

Jun. 8, 2021

Rule 836-053-0473’s source at or​.us