Montana Code 33-22-157. Standards for review — notice of deficiency
33-22-157. Standards for review — notice of deficiency. (1) (a) When reviewing a premium rate filing, the commissioner shall consider whether the proposed premium rate is excessive, inadequate, unjustified, or unfairly discriminatory. Rates may be considered excessive if they cause the premium charged for the health insurance coverage to be unreasonably high in relation to the benefits provided under the coverage. In order to determine if the rate is excessive, the commissioner shall consider whether:
Terms Used In Montana Code 33-22-157
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health insurance coverage: means benefits consisting of medical care, including items and services paid for as medical care, that are provided directly, through insurance, reimbursement, or otherwise, under a policy, certificate, membership contract, or health care services agreement offered by a health insurance issuer. See Montana Code 33-22-140
- Health insurance issuer: means an insurer, a health service corporation, or a health maintenance organization. See Montana Code 33-22-140
- Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201
(i)the assumptions on which the rate increase is based are reasonable; and
(ii)one or more of the assumptions is not supported by the evidence.
(b)Rates may be considered inadequate if the rate is unreasonably low for the coverage provided, and the commissioner may consider if the rate would endanger the solvency of the insurer or disrupt the insurance market in Montana.
(c)A rate increase may be considered unjustified if the health insurance issuer provides data or documentation in connection with the increase that is incomplete, inadequate, or otherwise does not provide a basis upon which the reasonableness of an increase may be determined.
(d)Rates may be considered unfairly discriminatory if they violate 33-18-206, 33-22-526, 49-2-309, or other applicable state laws prohibiting discrimination in health insurance.
(2)In order to determine whether the proposed premium rates for health insurance coverage are not excessive, inadequate, unjustified, or unfairly discriminatory, the commissioner may consider:
(a)the health insurance issuer’s financial position, including but not limited to surplus, reserves, and investment savings;
(b)historical and projected administrative costs and medical and hospital expenses, including medical trends;
(c)the historical and projected medical loss ratio;
(d)changes to covered benefits or health plan design, along with actuarial projections concerning cost savings or additional expenses related to those changes;
(e)changes in the health insurance issuer’s health care cost containment and quality improvement efforts following the health insurance issuer’s last rate filing for the same category of health plan;
(f)product development and startup costs, drug and other benefit costs or expenses, and product age and credibility;
(g)whether the proposed change in the premium rate is necessary to maintain the health insurance issuer’s solvency or to maintain rate stability and prevent excessive rate increases in the future;
(h)historical and projected claims experience;
(i)trend projections related to utilization and service or unit cost;
(j)allocation of the overall rate increase to claims and nonclaims costs;
(k)allocation of current and projected premium for each enrollee each month;
(l)the 3-year history of rate increases for the product or group of products associated with the rate increase if the product is 3 years old or older and otherwise any available rate history;
(m)employee and executive compensation data from the health insurance issuer’s annual financial statements; and
(n)any other applicable information identified in administrative rules adopted pursuant to Title 33, except that the administrative rules may not include by reference any provisions of Public Law 111-148 and Public Law 111-152 or any regulations promulgated under those laws.
(3)The commissioner shall review rate filings and, if applicable, shall provide a notice of deficiencies containing detailed reasons describing why the commissioner finds that the proposed premium rate is excessive, inadequate, unjustified, or unfairly discriminatory. The notice must be provided within 60 days of receipt of filing.
(4)Within 30 days after receiving a notice of deficiencies alleging that a proposed rate is excessive, inadequate, unjustified, or unfairly discriminatory, the insurer may amend its rate filing, request reconsideration based upon additional information, or, unless the rate is unfairly discriminatory pursuant to subsection (1)(d), implement the proposed rate.
(5)At the end of the 30-day period described in subsection (4), if the insurer implements a rate that the commissioner has determined to be excessive, inadequate, or unjustified, the commissioner shall publish the finding on the commissioner’s website indicating the commissioner’s determination.