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Epstein Becker Green
National Health Insurance Rate Review Scorecard



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
blue
States without an Effective Rate Review Program - Reviews conducted by CMS
orange
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
green



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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