SECTION 365:10-5-155. Restrictions relating to premium rates

(a)   Separate rate manuals required.

(1)   A small employer carrier shall develop a separate rate manual for each class of Business. Base premium rates and new business premium rates charged to small employers by the small employer carrier shall be computed solely from the applicable rate manual developed pursuant to 365:10-5-155(a). To the extent that a portion of the premium rates charged by a small employer carrier is based on the carrier's discretion, the manual shall specify the criteria and factors considered by the carrier in exercising such discretion.

(2)   Modification of rating method requirements.

(A)   A small employer carrier shall not modify the rating method used in the rate manual for a class of business until the change has been approved as provided in 365:10-5-155(a)(2). The Commissioner may approve a change to a rating method if the Commissioner finds that the change is reasonable, actuarially appropriate, and consistent with the purposes of the Act and this Part.

(B)   A carrier may modify the rating method for a class of business only with priorapproval of the Commissioner. A carrier requesting to change the rating method for a class of business shall make a filing with the Commissioner at least thirty (30) days prior or the proposed date of the change. The filing shall contain at least the following information:

(i)   The reasons the change in rating method is being requested;

(ii)   A complete description of each of the proposed modifications to the rating method;

(iii)   A description of how the change in rating method would affect the premium rates currently charged to small employers in the class of business, including an estimate from a qualified actuary of the number of groups or individuals (and a description of the types of groups or individuals) whose premium rates may change by more than ten percent (10%) due to the proposed change in rating method (not generally including increases in premium rates applicable to all small employers in a health benefit plan);

(iv)   A certification from a qualified actuary that the new rating method would be based on objective and credible data and would be actuarially sound and appropriate; and

(v)   A certification from a qualified actuary that the proposed change in rating method would not produce premium rates for small employers that would be in violation of 36 O.S.Supp.1994, §6515.

(C)   For the purpose of 365:10-5-155 a change in rating method shall mean:

(i)   A change in the number of case characteristics used by a small employer carrier to determine premium rates for health benefit plans in a class of business;

(ii)   A change in the manner or procedures by which insureds are assigned into categories for the purpose of applying a case characteristic to determine premium rates for health benefit plans in a class of business;

(iii)   A change in the method of allocating expenses among health benefit plans in a class of business; or

(iv)   A "ten percent charge in premium" test.

(I)   A change in rating factor with respect to any case characteristic if the change would produce a change in premium for any small employer that exceeds ten percent (10%).

(II)   For the purpose of 365:10-5-155 (a)(2)(C)(iv)(I), a change in a rating factor considered over a twelve (12) month period. If a small employer carrier changes rating factors with respect to more than one case characteristic in a twelve (12) month period, the carrier shall consider the cumulative effect of all such changes in applying the ten percent (10%) test under 365:10-5-155(a)(2)(C)(iv)(I).

(b)   Case characteristics and rate factors.

(1)   The rate manual developed pursuant to 356:10-5-155(a) shall specify the case characteristics and rate factors to be applied by the small employer carrier in establishing premium rates for the class of business.

(2)   A small employer carrier may not use case characteristics other than age, gender, industry, geographic area, and family composition, as specified in 36 O.S.Supp.1994, §6512(7), without the prior approval of the Commissioner. A small employer carrier seeking such an approval shall make a filing with the Commissioner for a change in rating method under 365:10-5-155(a)(2).

(3)   A small employer carrier shall use the same case characteristics in establishing premium rates for each health benefit plan in a class of business and shall apply them in the same manner in establishing premium rates for each such health benefit plan. Case characteristics shall be applied without regard to the risk characteristics of a small employer.

(4)   The rate manual developed pursuant to 365:10-5-155(a) shall clearly illustrate the relationship among the base premium rates charged for each health benefit plan in the class of business. If the new business premium rate is different than the base premium rate for a health benefit plan, the rate manual shall illustrate the difference.

(5)   Differences among base premium rates for health benefit plans shall be based solely upon the reasonable and objective differences in the design and benefits of the health benefit plans and shall not be based in any way on the actual or expected health status or claims experience of the small employer groups that choose or are expected to choose a particular health benefit plan. A small employer carrier shall apply case characteristics and rate factors within a class of business in a manner that assures that premium differences among health benefit plans for identical small employer groups vary only due to reasonable and objective differences in the design and benefits of the health benefit plans and are not due to the actual or expected health status or claims experience of the small employer groups that choose or are expected to choose a particular health benefit plan.

(6)   The rate manual developed pursuant to 365:10-5-155(a) shall provide for premium rates to be developed in a two step process. In the first step, a base premium rate shall be developed for the small employer group without regard to any risk characteristics of the group. In the second step, the resulting base premium rate may be adjusted by a risk load, subject to the provisions of 36 O.S.Supp.1994, §6515, to reflect the risk characteristics of the group.

(7)   A premium charged to a small employer for a health benefit plan shall not include a separate application fee, underwriting fee, or any other separate fee or charge.

(8)   A small employer carrier shall allocate administrative expenses to the basic and standard health benefit plans on no less favorable of a basis than expenses are allocated to other health benefit plans in the class of business. The rate manual developed pursuant to 365:10-5-155(a) shall describe the method of allocating administrative expenses to the health benefit plans in the class of business for which the manual was developed.

(9)   Each rate manual developed pursuant to 365:10-5-155(a) shall be maintained by the carrier for a period of six (6) years. Updates and changes to the manual shall be maintained with the manual.

(10)   The rate manual and rating practices of a small employer carrier shall comply with any guidelines issued by the Commissioner.

(c)   The restrictions related to changes in premium rates in 36 O. S.Supp.1994, §6515(A)(3) and (7), shall be applied as follows:

(1)   A small employer carrier shall revise its rate manual each rating period to reflect changes in base premium rates and changes in new business premium rates.

(2)   If, for any health benefit plan with respect to any rating period, the percentage change in the new business premium rate is less than or the same as the percentage change in the base premium rate, the change in the new business premium rate shall be deemed to be the change in the base premium rate for the purposes of 36 O.S.Supp.1994, §6515(A)(3)(c) and 36 O.S.Supp.1994, §6515(A)(7)(a).

(3)   If, for any health benefit plan with respect to any rating period, the percentage change in the new business premium rate exceeds the percentage change in the base premium rate, the health benefit plan shall be considered a health benefit plan into which the small employer carrier is no longer enrolling new small employers for the purposes of 36 O.S.Supp.1994, §6515(A)(3)(c) and 36 O.S.Supp.1994, §6515(A)(7)(a).

(4)   If, for any rating period, the change in the new business premium rate for a health benefit plan differs from the change in the new business premium rate for any other health benefit plan in the same class of business by more than twenty percent (20%), the carrier shall make a filing with the Commissioner containing a complete explanation of how the respective changes in new business premium rates were established and the reason for the difference. The filing shall be made within thirty (30) days of the beginning of the rating period.

(5)   A small employer carrier shall keep on file for a period of at least six (6) years the calculations used to determine the change in base premium rates and new business premium rates for each health benefit plan for each rating period.

(d)   Revised premium rate.

(1)   Except as provided in 365:10-5-155(e)(2) thru (4), a change in premium rate that is no more than the following:

(A)   The base premium rate for the small employer (as shown in the rate manual as revised for the rating period), multiplied by

(B)   One plus the sum of:

(i)   The risk load applicable to the small employer during the previous rating period, and

(ii)   Fifteen percent (15%) (prorated for periods of less than one year).

(2)   In the case of a health benefit plan into which a small employer carrier is no longer enrolling new small employers, a change in premium rate for a small employer shall produce a revised premium rate that is no more than the following:

(A)   The base premium rate for the small employer given its present composition and as shown in the rate manual in effect for the small employer at the beginning of the previous rating period, multiplied by

(B)   One plus the lesser of:

(i)   The change in the base rate or

(ii)   The percentage change in the new business premium for the most similar health benefit plan into which the small employer carrier is enrolling new small employers, multiplied by

(C)   One plus the sum of:

(i)   The risk load applicable to the small employer during the previous rating period and

(ii)   Fifteen percent (15%) (prorated for periods of less than one year).

(3)   In the case of a health benefit plan described in 36 O.S.Supp.1994, §6515(A)(6), if the current premium rate for the health benefit plan exceeds the ranges set forth in 36 O.S.Supp.1994, §6515(A), the formulae set forth in 365:10-5-155(e)(1) and (2) will be applied as if the fifteen percent (15%) adjustment provided in 365:10-5-155(e)(1)(B)(ii) and 365:10-5-155(e)(2)(C)(ii) were a zero percent adjustment.

(4)   Notwithstanding the provisions of 365:10-5-155(e)(1) and (2), a change in premium rate for a small employer shall not produce a revised premium rate that would exceed the limitations on rates provided in 36 O.S.Supp.1994, §6515(A)(2).

(e)   Taft-Hartley trust waiver request.

(1)   A representative of a Taft-Hartley trust (including a carrier upon the written request of such a trust) may file in writing with the Commissioner a request for the waiver of application of the provisions of 36 O.S.Supp.1994, §6515(A), with respect to such trust.

(2)   A request made under 365:10-5-155(f)(1) shall identify the provisions for which the trust is seeking the waiver and shall describe, with respect to each provision, the extent to which application of such provision would:

(A)   Adversely affect the participants and beneficiaries of the trust; and

(B)   Require modifications to one or more of the collective bargaining agreements under or pursuant to which the trust was or is established or maintained.

[Source: Added at 12 Ok Reg 3137, eff 7-31-95; Amended at 29 Ok Reg 1254, eff 7-14-12]