18 Del. Admin. Code § 1405-7.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1405-7.0 - Rating Requirements

7.1 An insurer offering a health benefit plan to an association or MEWA shall obtain rate approval from the Commissioner through the rate review process provided in 18 Del.C. Ch. 25. An insurer may use its existing group rates, without making an association or MEWA-specific rate filing, so long as its group rates have been filed with and approved by the Commissioner and meet the requirements of this Section.

7.2 No insurer shall offer a health benefit plan to an association or MEWA unless such association or MEWA meets the eligibility requirements of 18 Del.C. § 3506 in order to qualify for a group health insurance policy.

7.3 Any insurer contracting with an association or MEWA to provide a health benefit plan shall use a community rating methodology acceptable to the Commissioner in accordance with this Section and with the following:

7.3.1 The association or MEWA may be rated based on the collective group experience of its members, provided that each certificate holder and dependent is charged the same community rate; and

7.3.2 The following risk classification factors are prohibited in rating employees or members of such groups, and dependents of such employees or members:

7.3.2.1 Demographic rating, including age and gender rating;

7.3.2.2 Geographic area rating;

7.3.2.3 Health status rating, including pre-existing conditions;

7.3.2.4 Industry rating;

7.3.2.5 Medical underwriting and screening;

7.3.2.6 Experience rating;

7.3.2.7 Tier rating (except for tiers related to family structure); or

7.3.2.8 Durational rating.

7.4 The Commissioner may permit an insurer to establish rewards, premium discounts, split benefit designs, rebates, or otherwise waive or modify applicable co-payments, deductibles, or other cost-sharing amounts in return for adherence by a member or subscriber to programs of health promotion and disease prevention that are satisfactory to the Commissioner.

7.5 An insurer offering a health benefit plan to an association or a MEWA shall guarantee acceptance of all persons within the association or MEWA and their dependents.

7.6 An insurer offering a health benefit plan or plans to an association or a MEWA shall guarantee the rates on all such plans for a minimum of 12 months.

7.7 Medical Loss Ratio. A foreign or domestic insurer offering a health benefit plan to an association or MEWA with covered lives in Delaware shall comply, with respect to those covered lives, with the medical loss ratio and rebating requirements of 45 CFR 158.210-240, but shall in no case fall below eighty-five percent (85%) of the aggregate amount of premiums earned by the insurer from policies and certificates issued in this State.

7.8 Any fees associated with broker services shall not be incorporated into the medical loss ratio under subsection 7.7, but shall be incorporated in the administrative expense portion of an insurer's rate filing.

18 Del. Admin. Code § 1405-7.0

22 DE Reg. 509 (12/1/2018) (Final)