Epstein Becker Green
National Health Insurance Rate Review Scorecard
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Data as of March 2012. See also "Status Report on the Federal Health Insurance Rate Review Program."
Effective Rate Review Program? |
Applicable Rate Increase Threshold (September 2011-August 2012)[1] |
Agency/Division Responsible for Review |
Standard for Unreasonableness |
Rate Disapproval Authority? |
Recent Activity |
Minimum Medical Loss Ratio for Individual and Small Group Markets[2] |
|
United States |
As of October 2011, HHS determined that 44 states, the District of Columbia, and 3 territories have effective rate review programs in at least one of the two applicable markets |
10 percent |
Centers for Medicare & Medicaid Services (CMS) |
"Excessive," "unjustified," or "unfairly discriminatory"[3] |
No |
May 2011: HHS issues Final Rule on Rate Increase Disclosure and Review July 2011: HHS publishes list of states with effective rate review programs September 2011: HHS issues Amended Definitions of "individual market" and "small group market" to include policies sold through associations |
Under federal regulations (45 C.F.R. pt. 158) for 2011, the federal minimum medical loss ratio (MLR) is at least 80 percent for individuals and small groups, unless the state has received an adjustment from HHS, or the State has imposed a higher MLR |
No |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory"[4] |
Health care service plan and HMO rates[5] |
80 percent |
|||
Yes[6] |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[7] |
Yes |
80 percent |
|||
No |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory;"[8] filings of rate revisions must also be accompanied by an actuarial certification that rates comply with state rating laws[9] |
Initial rates in the individual market[10] |
80 percent |
|||
Yes |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[11] |
Individual market rates |
80 percent |
|||
Yes |
10 percent |
California Department of Managed Health Care and California Department of Insurance |
"The same meaning as that term is defined in PPACA"[12] |
No |
80 percent |
||
Yes |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[13] |
Yes |
80 percent |
|||
Yes |
10 percent |
"Excessive," "inadequate," or "discriminatory"[14] |
Individual market and HMO rates |
80 percent |
|||
Yes |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[15] |
Yes |
80 percent[16] |
|||
Yes |
10 percent |
District of Columbia Department of Insurance, Securities and Banking |
"Excessive," "inadequate," or "unfairly discriminatory"[17] |
Individual market, HMO, and Blue Cross Blue Shield rates |
80 percent |
||
Yes Associations: Partial |
10 percent |
Benefits are not "reasonable" in relation to the premium rate; filings must be accompanied by actuarial certification that rates comply with rating laws[18] |
Yes |
80 percent[19] |
|||
Yes |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[20] |
No |
75 percent[21] |
|||
Yes Associations: No |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory;" must also be "reasonable" in relation to the costs of the benefits provided[22] |
Yes |
80 percent |
|||
Yes Associations: No |
10 percent |
"Benefits are not "reasonable" in relation to the premium charged[23] |
No |
80 percent |
|||
Yes |
10 percent |
Benefits are not "reasonable" in relation to the premium charged[24] |
No |
80 percent |
|||
Yes |
10 percent |
Benefits are "not reasonable" in relation to the premium charged[25] |
Yes |
80 percent[26] |
|||
Yes |
10 percent |
|
Benefits are "unreasonable" in relation to the premium charged[27] |
Yes |
Individual market: 75 percent[28] Small group market: 80 percent | ||
Yes |
10 percent |
"Unreasonable," "excessive," or "unfairly discriminatory;"[29] or benefits are "unreasonable" in relation to the premium charged[30] |
Yes |
80 percent[31] |
|||
Yes Associations: Partial |
10 percent |
Benefits are "unreasonable" in relation to the premium charged; rates must not be "excessive," "inadequate," or "unfairly discriminatory"[32] |
Yes |
80 percent[33] |
|||
No |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory"[34] |
No |
80 percent[35] |
|||
Yes |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory"[36] |
Yes |
Individual market: 65 percent[37] Small group market: 80 percent | |||
Yes |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[38] |
Yes |
80 percent |
|||
Yes |
10 percent |
Benefits are "unreasonable" in relation to the rate charged; rates must also not be "excessive," "inadequate," or "unfairly discriminatory;"[39] rate filings must also be accompanied by an actuarial opinion certifying that the rates conform to accepted actuarial practices[40] |
Yes |
March-August 2010: The Massachusetts Division of Insurance (DOI) disapproves 235 of 274 premium rate increases filed by health insurance carriers for small business and individual customers. For a discussion and analysis of the DOI's actions, administrative appeals, reversals and settlements, see Massachusetts Division of Insurance Rate Disapprovals Show Mixed Results; Implications for National Health Reform |
90 percent through September 30, 2012[41] | ||
Yes |
10 percent |
Blue Cross Blue Shield rates must be "equitable, adequate, and not excessive;" HMO rates must be "fair," "sound," "reasonable" in relation to the benefits provided, and not "unfairly discriminatory"[42] |
Blue Cross Blue Shield and HMO rates |
80 percent[43] |
|||
Yes |
10 percent |
Minnesota Department of Commerce, Office of Insurance Commissioner |
Benefits provided are "not reasonable" in relation to the premium charged; rate is "excessive" or "not adequate;" rate must also be justified by actuarial reasons and data[44] |
Yes |
80 percent |
||
Yes Associations: Partial |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[45] |
No |
80 percent |
|||
No |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory"[46] |
No |
80 percent |
|||
No |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory"[47] |
No |
80 percent |
|||
Yes Associations: Partial |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[48] |
Yes |
80 percent |
|||
Yes |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[49] |
Individual market, Blue Cross Blue Shield, and HMO rates |
80 percent[50] | |||
Yes |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[51] |
Yes |
Individual market: 75 percent[52] Small group market: 80 percent | |||
Yes |
10 percent |
New Jersey Department of Banking and Insurance, Division of Insurance |
Benefits are "unreasonable" in relation to the premium charged[53] |
Yes |
80 percent |
||
Yes |
10 percent |
"Actuarially [un]sound," "[un]reasonable," "excessive," "inadequate," or "unfairly discriminatory" [54] |
Yes |
80 percent |
|||
Yes |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[55] |
Yes |
82 percent[56] |
|||
Yes Associations: Partial |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[57] |
Yes |
80 percent[58] |
|||
Yes |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[59] |
Yes |
80 percent[60] |
|||
Yes |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[61] |
Individual market and HMO rates |
80 percent |
|||
Yes |
10 percent |
"Unreasonable," "excessive," "unjustified," or "unfairly discriminatory"[62] |
HMO and small group rates |
80 percent[63] |
|||
Yes Associations: Partial |
10 percent |
Benefits are "not reasonable" in relation to the premium charged[64] |
Yes |
80 percent |
|||
Yes[65] Associations: Partial |
10 percent |
Pennsylvania Insurance Department |
"Excessive," "inadequate," or "unfairly discriminatory"[66] |
Yes |
80 percent |
||
Yes Associations: Partial |
10 percent |
Rhode Island Division of Insurance Regulation, Office of the Health Insurance Commissioner |
"Consistent with the proper conduct of its business and with the interest of the public"[67] |
Yes |
80 percent |
||
Yes |
10 percent |
Benefits are "unreasonable" in relation to the premium charged;[68] small group rates must be based on "sound actuarial principles"[69] |
Individual market rates |
80 percent |
|||
Yes |
10 percent |
Rates are not "reasonable" in relation to the benefits available[70] |
Blue Cross Blue Shield and individual market commercial rates |
80 percent |
|||
Yes |
10 percent |
Benefits are not "reasonable" in relation to the premium charged[71] |
Yes |
80 percent |
|||
Yes |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[72] |
No |
80 percent[73] |
|||
Yes |
10 percent |
Benefits are not "reasonable" in relation to the premium charged[74] |
No |
80 percent |
|||
Yes Associations: Partial |
10 percent |
"Unfair," "unjust," "inequitable," "misleading," or "contrary to the law"[75] |
Yes |
80 percent |
|||
Individual market: Yes Small group market: No Associations: No |
10 percent |
Individual market: Virginia Bureau of Insurance Small group market: CMS |
Individual market: Benefits are not "reasonable" in relation to the premium charged[76] Small group market: "Excessive," "inadequate," or "unfairly discriminatory"[77] |
Individual market rates[78] |
80 percent |
||
Yes Associations: No |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[79] |
Yes |
80 percent |
|||
Yes |
10 percent |
Benefits are "unreasonable" in relation to the premium charged[80] |
Yes |
80 percent |
|||
Yes Associations: Partial |
10 percent |
"Excessive," "inadequate," "unfairly discriminatory," or the rate will "have or tend to have the effect of destroying competition or creating a monopoly"[81] |
No |
80 percent[82] |
|||
No |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory"[83] |
No |
80 percent |
|||
TERRITORIES |
|
|
| ||||
American Samoa |
No |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory"[84] |
No |
80 percent |
||
Guam |
Yes |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[85] |
Yes |
80 percent[86] |
||
Northern Marianas Islands |
No |
10 percent |
"Excessive," "unjustified," or "unfairly discriminatory"[87] |
No |
80 percent |
||
Puerto Rico |
Yes |
10 percent |
"Excessive," "inadequate," or "unfairly discriminatory"[88] |
Yes |
80 percent |
||
Virgin Islands |
Yes |
10 percent |
United States Virgin Islands Division of Banking and Insurance |
Actuarially unjustified[89] |
Yes |
80 percent |
ENDNOTES
[1] The applicable threshold for all states will be 10 percent until September 1, 2012, at which point HHS-published state-specific thresholds will apply.
[2] These medical loss ratios apply only to commercial insurance rates in the individual and small group markets.
[3] 45 C.F.R. § 154.102.
[4] Id.
[5] The state, not CMS, has disapproval authority over these rates.
[6] As of January 1, 2012, the state has effective rate review authority in all markets.
[7] Alaska Stat. § 21.87.190.
[8] 45 C.F.R. § 154.102.
[9] Ariz. Admin. Code § R20-6-607.
[10] The state, not CMS, has disapproval authority over these rates.
[11] Ark. Code Ann. § 23-79-110(5)(A).
[12] Cal. Ins. Code § 10181.
[13] Colo. Rev. Stat. § 10-16-107.
[14] Conn. Gen. Stat. § 38a-183.
[15] Del. Code Ann. § 2503.
[16] Delaware unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketreforms/mlr/states/d elaware/de_mlr_adj_determination_letter.pdf.
[17] D.C. Code Ann. §§ 31-3508; 31-3415.
[18] Fla. Stat. § 627.410.
[19] Florida unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketreforms/mlr/states/Florida/2011%201215%20FL%20MLR%20Adj%20Determination%20Letter.pdf.
[20] Ga. Code Ann. § 33-9-4.
[21] Georgia requested adjustment from the federal MLR standard to 65 percent, 70 percent, and 75 percent for 2011, 2012, and 2013, respectively. HHS decided to adjust the MLR standard for Georgia's individual market to 70 percent for 2011, 75 percent for 2012, and 80 percent, the federal MLR standard, for 2013 and thereafter. See http://cciio.cms.gov/programs/marketreforms/mlr/states /georgia/final_ga_mlr_adj_determination_letter.pdf.
[22] Haw. Rev. Stat. § 431:14G-103(a).
[23] Idaho Code. Ann. §§ 41-4706; 41-5206.
[24] Ill. Comp. Stat. 5/355.
[25] Ind. Code §§ 27-8-5-1.5; 27-13-20-1.
[26] Indiana unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketreforms/mlr/states/i ndiana/in_mlr_adj_determination_letter.pdf.pdf.
[27] Iowa Code § 514A.14.
[28] Iowa requested adjustment from the federal MLR standard to 60 percent, 70 percent, and 75 percent for 2011, 2012, and 2013, respectively. HHS decided to adjust the MLR standard for Iowa's individual market to 67 percent for 2011, 75 percent for 2012, and 80 percent, the federal MLR standard, for 2013 and thereafter. See http://cciio.cms.gov/programs/marketreforms/mlr/states/iowa/ia _mlr_adj_determination_letter.pdf.
[29] Kan. Stat. Ann. § 40-2215(d)(1).
[30] Id. at § 40-2215(f)(2).
[31] Kansas unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketreforms /mlr/states/kansas/2012_0104_ks_mlr_adj_determination_letter_final.pdf.
[32] Ky. Rev. Stat. §§ 304.17-383; 304.17A-095.
[33] Kentucky requested adjustment from the federal MLR standard to 65 percent, 70 percent, and 75 percent for 2011, 2012, and 2013, respectively. HHS decided to adjust the MLR standard for Kentucky's individual market to 75 percent for 2011. See http://cciio.cms.gov/programs/marketreforms/mlr/states/Ke ntucky/ky_mlr_adj_determination_letter.pdf.
[34] 45 C.F.R. § 154.102.
[35] Louisiana unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketreforms/mlr/states /louisiana/la_mlr_adj_determination_letter.pdf.pdf.
[36] Me. Rev. Stat. Ann. §§ 2736; 2808-B.
[37] Maine successfully obtained adjustment from the federal MLR standard to 65 percent for its individual market for 2011, 2012, and 2013. See http://cciio.cms.gov/programs/marketreforms/mlr/states/maine/ maine_decision_letter_3_8_11.pdf.
[38] Md. Ins. Code Ann. § 11-205.
[39] Mass. Gen. Laws ch. 176G, § 16.
[40] 211 Mass. Code Regs. 66.09.
[41] 211 Mass. Code Regs. 66.09(1)(k). Pursuant to state law, the MLR standard was 88 percent in 2011. Id.
[42] Mich. Comp. Laws §§ 550.1608; 500.3519.
[43] Michigan unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/resources/files/Files2/12232011/mi_mlr_adj_determin ation_letter.pdf.
[44] Minn. Stat. § 62A.02(3).
[45] Miss. Code Ann. § 83-41-331.
[46] 45 C.F.R. § 154.102.
[47] 45 C.F.R. § 154.102.
[48] Neb. Rev. Stat. § 44-710.
[49] Nev. Rev. Stat. § 686B.050.
[50] Nevada requested adjustment from the federal MLR standard to 72 percent. HHS decided to adjust the MLR standard for Nevada's individual market to 75 percent for 2011. See http://cciio.cms.gov/programs/marketreforms/mlr/states/neva da/mlr_adj_decision_letter_5_13_11.pdf.
[51] N.H. Rev. Stat. Ann. § 415:2.
[52] New Hampshire requested adjustment from the federal MLR standard to 70 percent. HHS decided to adjust the MLR standard for New Hampshire's individual market to 72 percent for 2011, 75 percent for 2012, and 80 percent, the federal MLR standard, for 2013 and thereafter. See http://cciio.cms.gov/programs/marketreforms/mlr/nh_mlr_adj_decletter.pdf.
[53] N.J. Rev. Stat. § 17B:26-1.
[54] New Mexico SB 208.
[55] N.Y. Ins. Law. § 4308.
[56] In 2010, Governor's Program Bill No. 278 was signed, increasing the MLR for the individual and small group markets in New York to 82 percent. In addition, the bill gave the New York State Insurance Department prior approval authority over health insurance rate increases. See http://www.ins.state.ny.us/press/2010/p1006092.htm.
[57] N.C. Gen. Stat. § 58-51-95.
[58] North Carolina requested adjustment from the federal MLR standard to 72 percent, 74 percent, and 76 percent for 2011, 2012, and 2013, respectively. HHS decided to adjust the MLR standard for North Carolina's individual market to 75 percent for 2011. See http://cciio.cms.gov/programs/marketreforms/mlr/states/nc _mlr/2012_0216_nc_determination_letter.pdf.
[59] N.D. Cent. Code § 26.1-30-19.
[60] North Dakota unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketreforms/mlr/states /northdakota/nd_mlr_adj_determination_letter.pdf.
[61] Ohio Rev. Code Ann. § 3923.021.
[62] HB 2072 and SB 778, which took effect on August 26, 2011, require every health benefit plan to file all individual and small group plan initial rates and rate adjustments with the Insurance Commissioner. The Commissioner will then determine whether the rate is unreasonable, and if so, will make a written decision stating the reasons for the determination.
[63] Oklahoma unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketrefo rms/mlr/states/Oklahoma/2012_0104_ok_mlr_adj_determination_letter_final.pdf.
[64] Or. Rev. Stat. § 742.005.
[65] As of March 21, 2012, the state has effective rate review authority in all markets. Act 134 of 2011.
[66] Act 159 of 1996.
[67] R.I. Gen. Laws § 42-62-13.
[68] S.C. Code Ann. § 38-71-310(B).
[69] Id. at § 38-71-970.
[70] S.D. Codified Laws § 58-17-4.2.
[71] Tenn. Code Ann. § 56-26-102.
[72] Tex. Admin. Code § 11.702.
[73] Texas unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketrefor ms/mlr/states/texas/012712_FINAL_TX_MLR_Adj_Determination_Letter.pdf.pdf.
[74] Utah Code Ann. § 31A-22-602.
[75] Vt. Stat. Ann. § 4062.
[76] 14 Va. Admin. Code § 5-130-70.
[77] 45 C.F.R. § 154.102.
[78] The state, not CMS, has disapproval authority over these rates.
[79] Wash. Rev. Code § 48.18.110.
[80] W. Va. Code § 33-6-9.
[81] Wis. Stat. § 625.11.
[82] Wisconsin unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marketrefor ms/mlr/states/Wisconsin/2012_0216_final_wi_mlr_adj_determination_letter.pdf.
[83] 45 C.F.R. § 154.102.
[84] Id.
[85] 22 Guam Code Ann. § 18502.
[86] Guam unsuccessfully applied for a waiver from the federal MLR standard of 80 percent. See http://cciio.cms.gov/programs/marke treforms/mlr/states/Guam/2011_0805_guam_mlr_adjustment_determination_letter.pdf.pdf.
[87] 45 C.F.R. § 154.102.
[88] P.R. Laws Ann. tit. 26, § 1204.
[89] V.I. Code Ann. tit. 22, § 53a.