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National Health Insurance Rate Review Scorecard

RESOURCE LINKS

HHS Rate Review Lookup Tool (by State and Insurance Carrier)

CCIIO Rate Review Resources

CCIIO State Rate Review Instruction Manual

HHS State Rate Review Training Presentation

Health Insurance Oversight System (HIOS) Technical Manual

HIOS Sign-In Page

IMPORTANT DATES

September 1, 2011
Effective date of CMS Rate Review Regulations

November 1, 2011
Rate Reviews include all individual and small group coverage sold through associations

By June 1, 2012
Publication of state specific rate review thresholds effective September 1, 2012. See "No Change in the 10 Percent Federal Rate Review Threshold."

COLOR KEY
States with an Effective Rate Review Program - Reviews conducted by the State
States without an Effective Rate Review Program - Reviews conducted by CMS
States with an Effective Rate Review Program for either the Individual or Small Group Market only - Reviews conducted by CMS or the State, depending on the market

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
Alabama	No	10 percent	CMS	“Excessive,” “unjustified,” or “unfairly discriminatory”[4]	Health care service plan and HMO rates[5]		80 percent
Alaska	Yes[6]	10 percent	Alaska Division of Insurance	“Excessive,” “inadequate,” or “unfairly discriminatory”[7]	Yes		80 percent
Arizona	No	10 percent	CMS	“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
Arkansas	Yes	10 percent	Arkansas Insurance Department	Benefits are “unreasonable” in relation to the premium charged[11]	Individual market rates		80 percent
California	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
Colorado	Yes	10 percent	Colorado Division of Insurance	“Excessive,” “inadequate,” or “unfairly discriminatory”[13]	Yes		80 percent
Connecticut	Yes	10 percent	Connecticut Insurance Department	“Excessive,” “inadequate,” or “discriminatory”[14]	Individual market and HMO rates		80 percent
Delaware	Yes	10 percent	Delaware Department of Insurance	“Excessive,” “inadequate,” or “unfairly discriminatory”[15]	Yes		80 percent[16]
District of Columbia	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
Florida	Yes Associations: Partial	10 percent	Florida Office of Insurance Regulation	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]
Georgia	Yes	10 percent	Georgia Office of Insurance and Safety Fire Commissioner	“Excessive,” “inadequate,” or “unfairly discriminatory”[20]	No		75 percent[21]
Hawaii	Yes Associations: No	10 percent	Hawaii Insurance Division	“Excessive,” “inadequate,” or “unfairly discriminatory;” must also be “reasonable” in relation to the costs of the benefits provided[22]	Yes		80 percent
Idaho	Yes Associations: No	10 percent	Idaho Department of Insurance	“Benefits are not “reasonable” in relation to the premium charged[23]	No		80 percent
Illinois	Yes	10 percent	Illinois Department of Insurance	Benefits are not “reasonable” in relation to the premium charged[24]	No		80 percent
Indiana	Yes	10 percent	Indiana Department of Insurance	Benefits are “not reasonable” in relation to the premium charged[25]	Yes		80 percent[26]
Iowa	Yes	10 percent	Iowa Insurance Division	Benefits are “unreasonable” in relation to the premium charged[27]	Yes		Individual market: 75 percent[28] Small group market: 80 percent
Kansas	Yes	10 percent	Kansas Insurance Department	“Unreasonable,” “excessive,” or “unfairly discriminatory;”[29] or benefits are “unreasonable” in relation to the premium charged[30]	Yes		80 percent[31]
Kentucky	Yes Associations: Partial	10 percent	Kentucky Department of Insurance	Benefits are “unreasonable” in relation to the premium charged; rates must not be “excessive,” “inadequate,” or “unfairly discriminatory”[32]	Yes		80 percent[33]
Louisiana	No	10 percent	CMS	“Excessive,” “unjustified,” or “unfairly discriminatory”[34]	No		80 percent[35]
Maine	Yes	10 percent	Maine Bureau of Insurance	“Excessive,” “unjustified,” or “unfairly discriminatory”[36]	Yes		Individual market: 65 percent[37] Small group market: 80 percent
Maryland	Yes	10 percent	Maryland Insurance Administration	Benefits are “unreasonable” in relation to the premium charged[38]	Yes		80 percent
Massachusetts	Yes	10 percent	Massachusetts Division of Insurance	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]
Michigan	Yes	10 percent	Michigan Office of Financial and Insurance Regulation	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]
Minnesota	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
Mississippi	Yes Associations: Partial	10 percent	Mississippi Insurance Department	“Excessive,” “inadequate,” or “unfairly discriminatory”[45]	No		80 percent
Missouri	No	10 percent	CMS	“Excessive,” “unjustified,” or “unfairly discriminatory”[46]	No		80 percent
Montana	No	10 percent	CMS	“Excessive,” “unjustified,” or “unfairly discriminatory”[47]	No		80 percent
Nebraska	Yes Associations: Partial	10 percent	Nebraska Department of Insurance	Benefits are “unreasonable” in relation to the premium charged[48]	Yes		80 percent
Nevada	Yes	10 percent	Nevada Division of Insurance	“Excessive,” “inadequate,” or “unfairly discriminatory”[49]	Individual market, Blue Cross Blue Shield, and HMO rates		80 percent[50]
New Hampshire	Yes	10 percent	New Hampshire Insurance Department	Benefits are “unreasonable” in relation to the premium charged[51]	Yes		Individual market: 75 percent[52] Small group market: 80 percent
New Jersey	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
New Mexico	Yes	10 percent	New Mexico Public Regulation Commission, Insurance Division	“Actuarially [un]sound,” “[un]reasonable,” “excessive,” “inadequate,” or “unfairly discriminatory” [54]	Yes		80 percent
New York	Yes	10 percent	New York State Insurance Department	“Excessive,” “inadequate,” or “unfairly discriminatory”[55]	Yes		82 percent[56]
North Carolina	Yes Associations: Partial	10 percent	North Carolina Department of Insurance	Benefits are “unreasonable” in relation to the premium charged[57]	Yes		80 percent[58]
North Dakota	Yes	10 percent	North Dakota Insurance Department	Benefits are “unreasonable” in relation to the premium charged[59]	Yes		80 percent[60]
Ohio	Yes	10 percent	Ohio Department of Insurance	Benefits are “unreasonable” in relation to the premium charged[61]	Individual market and HMO rates		80 percent
Oklahoma	Yes	10 percent	Oklahoma Insurance Department	“Unreasonable,” “excessive,” “unjustified,” or “unfairly discriminatory”[62]	HMO and small group rates		80 percent[63]
Oregon	Yes Associations: Partial	10 percent	Oregon Insurance Division	Benefits are “not reasonable” in relation to the premium charged[64]	Yes		80 percent
Pennsylvania	Yes[65] Associations: Partial	10 percent	Pennsylvania Insurance Department	“Excessive,” “inadequate,” or “unfairly discriminatory”[66]	Yes		80 percent
Rhode Island	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
South Carolina	Yes	10 percent	South Carolina Department of Insurance	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
South Dakota	Yes	10 percent	South Dakota Division of Insurance	Rates are not “reasonable” in relation to the benefits available[70]	Blue Cross Blue Shield and individual market commercial rates		80 percent
Tennessee	Yes	10 percent	Tennessee Insurance Division	Benefits are not “reasonable” in relation to the premium charged[71]	Yes		80 percent
Texas	Yes	10 percent	Texas Department of Insurance	“Excessive,” “inadequate,” or “unfairly discriminatory”[72]	No		80 percent[73]
Utah	Yes	10 percent	Utah Insurance Department	Benefits are not “reasonable” in relation to the premium charged[74]	No		80 percent
Vermont	Yes Associations: Partial	10 percent	Vermont Insurance Division	“Unfair,” “unjust,” “inequitable,” “misleading,” or “contrary to the law”[75]	Yes		80 percent
Virginia	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
Washington	Yes Associations: No	10 percent	Washington State Office of the Insurance Commissioner	Benefits are “unreasonable” in relation to the premium charged[79]	Yes		80 percent
West Virginia	Yes	10 percent	West Virginia Offices of the Insurance Commissioner	Benefits are “unreasonable” in relation to the premium charged[80]	Yes		80 percent
Wisconsin	Yes Associations: Partial	10 percent	Wisconsin Office of the Commissioner of Insurance	“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]
Wyoming	No	10 percent	CMS	“Excessive,” “unjustified,” or “unfairly discriminatory”[83]	No		80 percent
TERRITORIES
American Samoa	No	10 percent	CMS	“Excessive,” “unjustified,” or “unfairly discriminatory”[84]	No		80 percent
Guam	Yes	10 percent	Guam Department of Revenue and Taxation	“Excessive,” “inadequate,” or “unfairly discriminatory”[85]	Yes		80 percent[86]
Northern Marianas Islands	No	10 percent	CMS	“Excessive,” “unjustified,” or “unfairly discriminatory”[87]	No		80 percent
Puerto Rico	Yes	10 percent	Puerto Rico Office of the Commissioner of Insurance	“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/delaware/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/indiana/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/Kentucky/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_determination_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/nevada/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/marketreforms/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/marketreforms/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/marketreforms/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/marketreforms/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.

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