230 R.I. Code R. 230-RICR-20-30-10.12

Current through December 3, 2024

Section 230-RICR-20-30-10.12 - Annual Filings

A. Annual filing required.

1. A small employer carrier shall make three annual filings with the health insurance commissioner:

a. a rate/trend filing,

b. an actuarial certification, and

c. an informational filing.

2. These filings must comply with the requirements of § 10.12 of this Part.

B. Rate/trend filing.

1. No later than May 15 of each year, or at such other date specified by the Commissioner, each small employer carrier shall make an annual rate/trend filing that contains trend factors and other information in support of the rates proposed to be charged or a rating formula proposed to be used by the carrier in the small employer market for periods which do not already have approved rate factors. The trend filing shall conform to the template specified by the commissioner by bulletin and posted on the OHIC website. Upon receiving the filing, the commissioner shall make an initial review of the filing, and either determine that the filing is complete, or notify the carrier what additional information is needed for the filing to be determined to be complete. The commissioner shall notify each carrier once the filing is determined to be complete. In the commissioner's discretion, OHIC may send a copy of the carrier's completed filing to the department of the attorney general. Once the filing is determined to be complete, the commissioner shall issue a decision with respect to the filing in accordance with R.I. Gen. Laws §§ 27-19-6, 27-20-6, and 42-62-13. Nothing in this subdivision shall be construed to prevent a carrier from filing proposed rates or a rating formula in accordance with R.I. Gen. Laws §§ 27-19-6, 27-20-6, and 42-62-13 at other times when warranted under the circumstances.

2. The commissioner may consult with such actuarial or other persons with relevant expertise employed by or under contract with OHIC or the department of business regulation. The written analysis conducted by such experts shall be entered into the record of the commissioner's review and distributed to the parties, and may be considered by the commissioner in making a decision with respect to the carrier's filing. Such written analysis shall also be entered into the evidentiary record of a hearing held under § 10.12 of this Part, and consistent with applicable law, including but not limited to R.I. Gen. Laws §§ 42-35-9 and 42-35-13, may be considered by the commissioner or the commissioner's designee in connection with any final order following such hearing.

3. The rates proposed to be charged or the rating formula proposed to be used by a small employer carrier shall be based on a minimum projected loss ratio of eighty percent (80%). As used in § 10.12(B)(3) of this Part, "loss ratio" means the ratio calculated by dividing the carrier's health care claims experience by premium.

4. Decision by the commissioner; hearings.

a. In accordance with the time periods established by with R.I. Gen. Laws §§ 27-19-6, 27-20-6, and 42-62-13, and after the commissioner determines the filing is complete, the commissioner shall either accept the filing, make recommendations to the carrier as to how the filing should be amended, or notice a hearing.

(1) If the commissioner recommends amendments to the filing, the carrier shall be provided with an opportunity to amend its filing in conformity to the recommended amendments. If the carrier amends its filing in conformity with the recommended amendments, the commissioner shall approve the filing.

(2) If the carrier does not amend its filing, the commissioner shall notice a hearing on the filing determined to be complete. The hearing will be held within sixty days after the filing has been determined to be complete, upon not less than ten days prior written notice. The hearing notice shall contain a description of the rates proposed to be charged or the rating formula proposed to be used, and a copy of the notice shall be sent to the carrier and to the department of attorney general.

(3) If the commissioner does not recommend amendments and determines that there should be a hearing, the hearing will be held within sixty days after the filing has been determined to be complete, upon not less than ten days prior written notice. The hearing notice shall contain a description of the rates proposed to be charged or the rating formula proposed to be used, and a copy of the notice shall be sent to the carrier and to the department of attorney general.

b. At a hearing, the carrier shall be required to establish, in accordance with R.I. Gen. Laws §§ 27-19-6, 27-20-6, and 42-62-13, that the rates proposed to be charged or the rating formula proposed to be used are consistent with the proper conduct of its business, and with the interest of the public, and with all other applicable laws, regulations and orders of the commissioner.

c. Conduct of the hearing. The hearing shall be conducted in accordance with the R.I. Gen. Laws Chapter 42-35 (Administrative Procedures), and any orders as to the conduct of the hearing issued by the commissioner, or the commissioner's designee. The commissioner, or the commissioner's designee, may administer oaths, examine and cross examine witnesses, receive oral and documentary evidence, and shall have the power to subpoena witnesses, compel their attendance and require the production of all books, papers, records, correspondence, or other documents which he or she deems relevant. Any designee who shall conduct a hearing pursuant to § 10.12 of this Part shall report his or her findings in writing to the commissioner within eighty days of the date the filing was determined to be complete with a recommendation for approval, disapproval, or modification of the rates proposed to be charged or the rating formula proposed to be used by the applicant, unless the time for making such recommendation has been extended by agreement of the parties to the hearing. The recommended decision shall become part of the record. The commissioner shall make and issue a decision not later than ten days following the issuance of the recommended decision or, if the commissioner conducts the hearing without the appointment of a designee, as soon as is reasonably possible following the completion of the hearing. The decision may approve, disapprove, or modify the rates proposed to be charged or the rating formula proposed to be used by the carrier and may take into consideration any of this information required to be filed under § 10.12 of this Part.

d. Carriers shall underwrite the reasonable expenses incurred by the Office in connection with the hearing, including but not limited to any costs related to advertisements, stenographic reporting, expert witness fees, actuarial fees and the per diem cost of the designee as appointed by the commissioner.

e. The commissioner's designee means a person who is impartial, a member in good standing of the Rhode Island bar and a person who is sufficiently acquainted with the rules of evidence as used in the superior court of the state so as to enable that person to conduct a hearing as designee of the commissioner.

f. A carrier that is aggrieved by the commissioner's decision after a hearing may move for reconsideration by the commissioner within twenty days of the date of the decision. The commissioner shall issue a decision on the motion for reconsideration within ten days of receiving the motion. Such motions may be granted by the commissioner for the following reasons: mistake, inadvertence, surprise, or excusable neglect; newly discovered evidence which by due diligence could not have been discovered in time for presentation at the hearing; fraud, misrepresentation, or other misconduct of an adverse party; or any other reason justifying relief from the decision. A party is not required to file a motion for reconsideration prior to appeal of the decision pursuant to R.I. Gen. Laws § 42-35-15. However, if a carrier files a timely motion for reconsideration, carrier will not be considered to have fully exhausted all administrative remedies until a decision has been issued by the commissioner on the motion.

g. A carrier that is aggrieved by the commissioner's decision after exhausting all available administrative remedies is entitled to appeal the commissioner's decision in accordance with R.I. Gen. Laws § 42-35-15.

h. A carrier may request a hearing on its filing at any time prior to a final decision by the commissioner to accept a filing or an amended filing.

C. Actuarial certification.

1. No later than March 15 of each year, each small employer carrier shall file an actuarial certification with the Office. The actuarial certification shall be made by an appointed actuary and shall certify that the carrier is in compliance with the Act and that the rating methods of the carrier are actuarially sound. The certification shall be in a form and manner specified by this regulation, shall contain the information required by this regulation and shall be signed by a qualified actuary. A copy of the certification shall be retained by the carrier at its principal place of business.

2. Standard for actuarial certification and associated analysis.

a. The certification shall be in the form of a written report, signed by the appointed actuary, and include such additional exhibits as may be required to support the conclusions and opinions stated in the certification. It should be prepared in accordance with Actuarial Standard of Practice No. 26 of the American Academy of Actuaries, "Compliance with Statutory and Regulatory Requirements for the Actuarial Certification of Small Employer Health Benefit Plans," and shall contain a statement to that effect.

b. The certification shall include, but not be limited to, the following areas of compliance:

(1) compliance with restrictions related to premium rates in R.I. Gen. Laws § 27-50-5;

(2) compliance with provisions related to renewability of coverage in R.I. Gen. Laws § 27-50-6;

(3) compliance with provisions related to availability of coverage in R.I. Gen. Laws § 27-50-7; and

(4) compliance with provisions related to certification of creditable coverage in R.I. Gen. Laws § 27-50-8.

c. The certification shall identify any instances of non-compliance in any of the above areas, and the number of instances of each type of non-compliance, the nature of the lack of compliance and the steps taken or recommended to correct non-compliance either retroactively or prospectively.

d. The certification shall contain a statement describing the extent, if any, to which the appointed actuary relied upon the work of others in reaching his or her conclusions. If the appointed actuary has relied upon the work of others, a statement from the person or persons relied upon describing the accuracy and completeness of the work shall be attached.

e. The appointed actuary shall maintain copies of all work papers necessary to support the conclusions reached in the certification for a minimum period of three years after the due date of the certification, and be prepared to explain the work done and/or produce the work papers to the commissioner or his or her designee upon request.

3. A qualified actuary is an individual who:

a. is a member in good standing of the American Academy of Actuaries;

b. is familiar with the requirements applicable to carriers under the Act;

c. is qualified to sign Prescribed Statements of Actuarial Opinion regarding compliance with small employer group health laws and regulations in accordance with the American Academy of Actuaries qualifications for actuaries signing such statements;

d. has not been found by the commissioner or his or her designee (or if so found has subsequently been reinstated as a qualified actuary), following appropriate notice and hearing to have:

(1) violated any provision of, or any obligation imposed by, Rhode Island's insurance laws or other law in the course of his or her dealings as a qualified actuary;

(2) been found guilty of fraudulent or dishonest practices;

(3) demonstrated his or her incompetence, lack of cooperation, or untrustworthiness to act as a qualified actuary;

(4) submitted to the commissioner during the past five years, pursuant to the Act, an actuarial opinion or memorandum that the commissioner rejected because it did not meet the provisions of this regulation including standards set by the Actuarial Standards Board; or

(5) resigned or been removed as an actuary within the past five years as a result of actions or omissions indicated in any adverse report on examination or as a result of failure to adhere to generally acceptable actuarial standards; and

e. has not failed to notify the commissioner of any action taken by any insurance commissioner of any other state similar to those described above.

4. An "appointed actuary" is a qualified actuary who is appointed or retained to prepare the Statement of Actuarial Opinion required by R.I. Gen. Laws § 27-50-5(h), either directly by or by the authority of the board of directors through an executive officer of the carrier. The carrier shall give the commissioner not less than thirty days written notice of the name, title (and, in the case of a consulting actuary, the name of the firm) and manner of appointment or retention of each person appointed or retained by the carrier as an appointed actuary and shall state in such notice that the person meets the requirements set forth in § 10.12 of this Part. Once notice is furnished, no further notice is required with respect to this person, provided that the carrier shall give the commissioner not less than thirty days written notice in the event the actuary ceases to be appointed or retained as an appointed actuary or to meet the requirements set forth in § 10.12 of this Part. If any person appointed or retained as an appointed actuary replaces a previously appointed actuary, the notice shall so state and give the reasons for replacement and that the replacement actuary meets the requirements hereof.

D. Informational filing

1. No later than March 15 of each year, each small employer carrier shall file an informational filing with the Office. The informational filing shall contain the following information:

a. the number of small employers that were issued health benefit plans in the previous calendar year (separated as to newly issued plans and renewals;

b. the number of small employers that were issued the HEALTHpact plan in the previous calendar year (separated as to newly issued plans and renewals);

c. the following information, based on small employer health benefit plans in force as of December 31 of the previous calendar year, provided separately for HEALTHpact plans, and provided separately for each other category of plan issued by the carrier (i.e. PPO, POS, HMO, etc.). Each plan shall be identified by summary description and SERFF filing number:

(1) the number of small employer plans in force.

(2) the number of contracts.

(3) the number of members.

d. information related to the entire previous calendar year, provided separately for HEALTHpact plans, and provided separately for each other health benefit plan issued by the carrier, including:

(1) contract months insured.

(2) member months insured.

(3) collected premium.

(4) paid claims.

e. information describing the efforts undertaken by the carrier to enhance the affordability of its products and implement policies and developments that improve the quality and efficiency of health care service delivery and outcomes in the state, as required by the commissioner; and

f. such other information as the commissioner determines is reasonable and necessary to carry out the purposes of the Act and this Regulation.

E. Public availability of filings.

1. Except for those documents or other information concerning which a party has requested, and the commissioner has approved confidential treatment, any information or documents contained in the filings or presented in support of the filings under § 10.12 of this Part shall be made available for public examination at any time and place that the commissioner may deem reasonable and shall also be posted on the commissioner's web site.

2. The attorney general, when the attorney general is a party to an administrative hearing, and any other party to an administrative hearing shall be provided notice and an opportunity to be heard with respect to any request for confidential treatment of information. The commissioner may order that such parties to an administrative hearing may have access to confidential information subject to appropriate protective orders.

3. A request for confidential treatment of documents and other information shall be made in the following manner. The request must be made directly to the commissioner, with a copy of the request provided to the commissioner's legal counsel. The request must identify and attach or enclose the specific documents or information for which confidential treatment is sought. The request must be accompanied by supporting factual and legal analysis with respect to whether the specific information for which confidential treatment is requested satisfies the statutory criteria of a "trade secret" under R.I. Gen. Laws § 6-41-1, or the criteria of any other statute upon which the request for confidential treatment is based; and whether the interests of the carrier in maintaining the confidentiality of the information outweighs the interests of the public in a transparent rate review process. See R.I. Gen. Laws § 42-62-13.

230 R.I. Code R. 230-RICR-20-30-10.12