# PR Carta Normativa Núm. CN-2014-175-AS: Radicaciones de Formularios y Tarifas Para el Año Natural de 2015

> Puerto Rico · Agency guidance · In force

URL: https://www.frixlaw.com/law-library/statutes/PR_INS_B_CN-2014-175-AS

## Section

- **Citation:** PR Carta Normativa Núm. CN-2014-175-AS
- **Heading:** Radicaciones de Formularios y Tarifas Para el Año Natural de 2015
- **Jurisdiction:** Puerto Rico
- **Kind:** Agency guidance
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Puerto Rico OCS Cartas Normativas y Cartas Circulares / Radicaciones de Formularios y Tarifas Para el Año Natural de 2015

## Text

ESTADO LIBRE ASOCIADO DE PUERTO RICO
OFICINA DEL COMISIONADO DE SEGUROS

B5 Calle Tabonuco, Oficina 216 • PMB 356 • Guaynabo, PR 00968-3029 • Tel.: (787) 304-8686 • Fax: (787) 304-0099
www.ocs.gobierno.pr

24 de marzo de 2014

CARTA NORMATIVA NÚM. CN-2014-175-AS

A TODOS LOS ASEGURADORES DE INCAPACIDAD Y ORGANIZACIONES DE
SERVICIOS DE SEGUROS DE SALUD QUE SUSCRIBEN PLANES MÉDICOS EN
PUERTO RICO

RADICACIONES DE FORMULARIOS Y TARIFAS PARA EL AÑO NATURAL DE
2015

Estimados señores y señoras:

Conforme a la Sección 2794 de la Ley Federal de Servicio de Salud Pública, enmendada
en la Sección 1003 de la ley federal de Protección del Paciente y Cuidado Accesible
(“ACA”), y de conformidad con los Capítulos 8 y 10 del Código de Seguros de Salud de
Puerto Rico, los aseguradores que suscriben planes médicos individuales y para grupos
pequeños en Puerto Rico deben presentar a la Oficina del Comisionado de Seguros
(“OCS”) las tarifas nuevas para los productos que cumplen con la ACA, todas las tarifas
para los planes que cumplan con la ACA aunque no se haya hecho ningún cambio y los
cambios que sean de 10% o más de las tarifas actuales, para la revisión y aprobación de
las mismas. Todas las organizaciones de servicios de salud (HMO) deben cumplir con
los requisitos de radicar las tarifas con la OCS, tal como se dispone en la Sección
19.080(2) (a) del Código de Seguros de Puerto Rico, 26 L.P.R.A., sec. 1908(2)(a) así como
de radicar todos los cambios o modificaciones de las tarifas, incluidas las tarifas de los
planes que cumplen con la ACA, aunque no se haya hecho ningún cambio.

En aras de implementar guías adecuadas para fomentar la presentación ordenada de los
formularios y las tarifas de los planes, que entrarán en vigor el 1 de enero de 2015, la
OCS por la presenta promulga las siguientes normas:

Presentación de Tarifas

I
bios o modificaciones de las tarifas, incluidas las tarifas de los
planes que cumplen con la ACA, aunque no se haya hecho ningún cambio.

En aras de implementar guías adecuadas para fomentar la presentación ordenada de los
formularios y las tarifas de los planes, que entrarán en vigor el 1 de enero de 2015, la
OCS por la presenta promulga las siguientes normas:

Presentación de Tarifas

I. Calendario

Las radicaciones de tarifas que entrarán en vigor el 1 de enero de 2015 para los planes
individuales y de grupos pequeños que tengan derechos adquiridos se deben presentar
a la OCS en o antes del 30 de mayo de 2014. Todo asegurador que se proponga hacer

2
cambios de tarifas trimestrales en los planes de grupos pequeños en 2015 debe radicar
las tarifas para todos los trimestres a más tardar el 31 de mayo de 2014.

Los aumentos de las tarifas para los planes individuales y de grupos pequeños de las
HMO con derechos adquiridos y los aumentos de tarifas mayores de 10% de los
aseguradores de incapacidad se tienen que radicar por lo menos con 90 días de
anticipación a la fecha de uso.

II. Requisitos para la radicación de tarifas

A. Toda radicación tiene que hacerse correctamente a través del sistema SERFF,
incluida la información que se requieren esta Carta Normativa y sus Anejos.
Véanse las instrucciones para radicar por SERFF en la Sección VI de esta
Carta Normativa.

B. Adviértase que las radicaciones incompletas se devolverán sin ser evaluadas.

C. Todos los archivos Excel se deben presentar en Excel, así como en formato
PDF para imprimir.

D. Toda radicación de tarifas se debe presentar conforme a los requisitos
establecidos en el Manual de Instrucciones para Radicar Tarifas en Puerto
Rico (Véase el Anejo 1).

E
ión VI de esta
Carta Normativa.

B. Adviértase que las radicaciones incompletas se devolverán sin ser evaluadas.

C. Todos los archivos Excel se deben presentar en Excel, así como en formato
PDF para imprimir.

D. Toda radicación de tarifas se debe presentar conforme a los requisitos
establecidos en el Manual de Instrucciones para Radicar Tarifas en Puerto
Rico (Véase el Anejo 1).

E. Se requiere que los siguientes documentos se incluyan en la radicación de
tarifas:

1) “Federal Rate Review Justification Part I-Unified Rate Review Template”
(URRT 2015 versión en Excel y en PDF) (Véase “Federal Instructions
Manual and Standard Format” en el Anejo 2);

2) Formato de la información que se colocará en el sitio Web de la OCS y se
usará en la Parte II de la justificación federal: “Written explanation of any
rate increase that is 10% or more”; (versiones en inglés y español);

3) Memorando Actuarial que cumpla con los requisitos de Puerto Rico y de
la Parte III del Memorando Actuarial federal y las Instrucciones de
Certificación 2.0 de 2014. (Véase el Anejo 3);

4) Certificación Actuarial de Puerto Rico;

5) Imágenes de las pantallas del “Actuarial Value Calculator” (para planes
que cumplen con la ACA solamente);

3

6) Plantilla SERFF de las tarifas (en Excel);

7) Manual de Tarifas;

8) Mapa de Beneficios Puerto Rico (si difiere del Mapa de Beneficios ya
radicado con la OCS o se debe indicar que ya se ha radicado el Mapa de
Beneficios (Véase el Anejo 4) y

9) Lista de Cotejo para las radicaciones de tarifas en Puerto Rico (Véase el
Anejo 5).

III. Uso de tarifas aprobadas y futuras revisiones

A. Los aseguradores solo pueden usar las tarifas radicadas y aprobadas por la
OCS.

B. No se pueden usar tarifas más bajas o más altas, aun cuando la tarifa revisada
es a nivel de grupo y la tarifa no es mayor que la tarifa aprobada. Nótese que
se harán auditorías para verificar que sólo se estén usando las tarifas
aprobadas.

C
5).

III. Uso de tarifas aprobadas y futuras revisiones

A. Los aseguradores solo pueden usar las tarifas radicadas y aprobadas por la
OCS.

B. No se pueden usar tarifas más bajas o más altas, aun cuando la tarifa revisada
es a nivel de grupo y la tarifa no es mayor que la tarifa aprobada. Nótese que
se harán auditorías para verificar que sólo se estén usando las tarifas
aprobadas.

C. No se permitirá que los aseguradores implementen cambios a las tarifas
actuales antes del 1 de enero de 2015, a menos que el asegurador pueda
probar que su solvencia económica disminuirá de manera peligrosa sin un
cambio de tarifas.

D. Una vez se aprueben las tarifas, no se pueden cambiar durante el año, a
menos que el asegurador pueda probar que su solvencia económica se verá
amenazada sin un cambio de tarifas.

E. Para el mercado de grupos pequeños, si las tarifas se aumentan
trimestralmente, se deben radicar por adelantado a la misma vez. No se
aceptará ningún otro aumento trimestral, a menos que el asegurador pueda
probarle a la OCS que las pérdidas proyectadas afectarían su solvencia.

4
IV. Tarifas que se publicarán

A. Los únicos documentos que se publicarán en el sitio Web de la OCS después
de la aprobación son las tarifas y el resumen público de la información de la
radicación preparado por el asegurador para colocarse en el sitio Web de la
OCS.

B. Todos los documentos se divulgarán simultáneamente el 1 de septiembre de
2014.

V. Radicación de las tarifas no sujetas a la nueva legislación

A. Toda radicación se deberá hacer por medio del sistema SERFF e incluir toda
la información que se requiere en esta Carta Normativa y sus Anejos. Véanse
las instrucciones para radicar las tarifas mediante SERFF en la Sección VI de
esta Carta Normativa.

B. Adviértase que toda radicación incompleta se devolverá sin evaluación
alguna.

C Todos los archivos Excel se presentarán en Excel, además del formato PDF
para impresión.

D
l sistema SERFF e incluir toda
la información que se requiere en esta Carta Normativa y sus Anejos. Véanse
las instrucciones para radicar las tarifas mediante SERFF en la Sección VI de
esta Carta Normativa.

B. Adviértase que toda radicación incompleta se devolverá sin evaluación
alguna.

C Todos los archivos Excel se presentarán en Excel, además del formato PDF
para impresión.

D. Todo aumento en las tarifas de los HMO y de los aseguradores de
incapacidad que sea de 10% o más de las tarifas del año anterior se deberá
presentar conforme a los requisitos establecidos en el Manual de
Instrucciones para Radicar Tarifas en Puerto Rico (Anejo 1).

E. Los documentos antes mencionados en la partida II (E) de esta Carta
Normativa se deben incluir en la radicación de las tarifas.

VI. Presentaciones mediante SERFF

A. En toda radicación mediante SERFF se debe incluir una Carta de Trámite que
indique el nombre del asegurador o la organización de servicios de salud que
hace la radicación bajo la firma de una persona autorizada, en cumplimiento
con la Sección 3(a)(1) de la Regla XXIV del Reglamento del Código de Seguros
de Puerto Rico. La carta de trámite se debe adjuntar en la sección “Supporting
Documentation”.

B. Se deben completar todos los campos indicados en la sección “Rate Rule
Schedule”.

5
C. Se debe incluir toda la documentación en la sección “Supporting
Documentation”, incluido el documento “Federal Rate Review Justification
Part I-Unified Rate Review Template” (URRT – tanto en el formato Excel
como en PDF), el formulario con la información sobre la radicación de tarifas
que se colocará en el sitio Web de la OCS, el Memorando Actuarial de Puerto
Rico, el Memorando Actuarial y la Certificación federal de 2014, la
Certificación Actuarial de Puerto Rico, las imágenes de la pantalla del
“Actuarial Value Calculator”, el Manual de Tarifas, el Mapa de Beneficios de
Puerto Rico y la Lista de Cotejo para la Radicación de Tarifas de Puerto Rico.

D
icación de tarifas
que se colocará en el sitio Web de la OCS, el Memorando Actuarial de Puerto
Rico, el Memorando Actuarial y la Certificación federal de 2014, la
Certificación Actuarial de Puerto Rico, las imágenes de la pantalla del
“Actuarial Value Calculator”, el Manual de Tarifas, el Mapa de Beneficios de
Puerto Rico y la Lista de Cotejo para la Radicación de Tarifas de Puerto Rico.

D. Las tarifas presentadas para aprobación se deben incluir en la sección “Rate
Rule Schedule”.

E. Los documentos se deben guardar en formato PDF sin protección, de manera
que se pueda realizar una búsqueda en el archivo y se pueda copiar texto del
documento.

F. Toda comunicación se debe incluir en el sistema SERFF como una “Note to
Reviewer (Nota al Revisor)” o “Response Letter (Carta de respuesta)”, como
sea aplicable. Cualquier otro medio de comunicación se dará por no recibido.

VII. Radicaciones de tarifas y formularios de grupos grandes

Las radicaciones para los grupos grandes no se deben presentar para la evaluación y
aprobación de la OCS. Esta norma no es aplicables a las HMO, las cuales tienen que
cumplir con las disposiciones de la Sección 19.080(2)(a) del Código de Seguros de
Puerto Rico.

Además, debemos señalar que los formularios de los grupos grandes están sujetos a
nuestra revisión y aprobación. Los formularios de los grupos tienen que cumplir con
todas las disposiciones aplicables de la ley ACA y del Código de Seguros de Salud de
Puerto Rico, que incluyen, entre otras, las siguientes Secciones de la ley de Servicio
Público de Salud: la Sección 2711 (Ausencia de límites anuales o vitalicios), la Sección
2713 (Cubierta de servicios de salud preventivos),1 la Sección 2714 (Extensión de
cubierta para dependientes), la Sección 2704 (Exclusiones de condiciones preexistentes).
Los formularios de los grupos grandes que no cumplan con la ley se tienen que
actualizar y radicar inmediatamente para la revisión y aprobación de esta Oficina
cción 2711 (Ausencia de límites anuales o vitalicios), la Sección
2713 (Cubierta de servicios de salud preventivos),1 la Sección 2714 (Extensión de
cubierta para dependientes), la Sección 2704 (Exclusiones de condiciones preexistentes).
Los formularios de los grupos grandes que no cumplan con la ley se tienen que
actualizar y radicar inmediatamente para la revisión y aprobación de esta Oficina.

“Supplemental Health Care Exhibit” (SHCE)

Por la presente se requiere que todos los aseguradores completen y envíen el
documento titulado “Supplemental Health Care Exhibit” a la NAIC y a la OCS antes del
30 de marzo, en el caso de los aseguradores de incapacidad, y antes del 31 de marzo de
cada año, en el caso de las organizaciones de servicio de salud.

1 No es aplicable a los planes con derechos adquiridos.

6

Radicaciones de productos

I. Calendario

Las radicaciones de productos de planes individuales y de grupos pequeños que entran
en vigor el 1 de enero de 2015 se deben presentar a la OCS a más tardar el 31 de mayo
de 2014.

II. Requisitos para la radicación de productos

A. Toda radicación se debe hacer por medio del sistema SERFF con toda la
información que se requiere en esta Carta Normativa y sus Anejos. Véanse las
instrucciones para radicaciones de productos mediante SERFF en la Sección
IV de la presente Carta Normativa.

B. No se aceptará ningún endoso de un producto que cumpla con la ACA
previamente aprobado.

C. Adviértase que toda radicación incompleta se devolverá sin evaluación
alguna.

D. Todos los formularios y documentos se deben presentar en formato PDF para
impresión.

E. Los siguientes documentos tienen que incluirse en la radicación del producto:
1. Lista de Cotejo de Beneficios Esenciales de Salud y Servicios Preventivos
(Véase el Anejo 6).
2. Lista de Cotejo para radicación de formularios de Puerto Rico (Véase el
Anejo 7).
F
devolverá sin evaluación
alguna.

D. Todos los formularios y documentos se deben presentar en formato PDF para
impresión.

E. Los siguientes documentos tienen que incluirse en la radicación del producto:
1. Lista de Cotejo de Beneficios Esenciales de Salud y Servicios Preventivos
(Véase el Anejo 6).
2. Lista de Cotejo para radicación de formularios de Puerto Rico (Véase el
Anejo 7).
F. Todos los productos y la estructura de copagos se tienen que radicar a la
misma vez y no se pueden cambiar durante el año.

G. No se podrá radicar ningún producto nuevo de clasificación metálica para ser
efectivo en el año 2014.

H. Los productos que cumplan con la ACA que estarán vigentes en el año
natural de 2015 solo deben incluir un límite de gastos pagados por el
beneficiario (MOOP), lo cual incluye los medicamentos recetados. El límite
del MOOP para el año 2015 establecido por nuestra Oficina es de $6,350 para
la cubierta que es solamente del beneficiario y $12,700 para todo otro tipo de
cubierta.
I. Los aseguradores deben mercadear todos los productos que cumplan con la
ACA y estén aprobados por la OCS.

7
III. Información de productos a divulgarse al público

La descripción de los beneficios de cada producto, los planes de niveles metálicos y la
tabla correspondiente de los copagos, coaseguro y deducibles se divulgarán
simultáneamente, luego de aprobarse, a todos los aseguradores el 1 de septiembre de
2014. La Tabla de Copagos, Coaseguro y Deducibles se debe presentar en el formato
Excel. (Véase el Anejo 9).

IV. Radicaciones por medio de SERFF

A. Toda radicación por medio de SERFF se debe acompañar con un Carta de
Trámite que indique el nombre del asegurador o de la organización de
servicios de salud que hace la radicación, firmada por una persona
autorizada, en cumplimiento con el Artículo 3(a)(1) de la Regla XXIV del
Reglamento del Código de Seguros de Puerto Rico. Las cartas de trámite se
deben anejar usando la sección “Supporting Documentation”.

B
medio de SERFF se debe acompañar con un Carta de
Trámite que indique el nombre del asegurador o de la organización de
servicios de salud que hace la radicación, firmada por una persona
autorizada, en cumplimiento con el Artículo 3(a)(1) de la Regla XXIV del
Reglamento del Código de Seguros de Puerto Rico. Las cartas de trámite se
deben anejar usando la sección “Supporting Documentation”.

B. Toda documentación de apoyo se debe incluir en la sección “Supporting
Documentation”, lo cual incluye la evidencia de aprobaciones anteriores, la
tabla de los copagos, coaseguro y deducibles, certificaciones y el memorando
de variables, entre otros.

C. Los formularios que se presenta para aprobación se deben incluir en la
sección “Form Schedule”.

D. Los formularios y los documentos se deben guardar en formato PDF sin
protección, de manera que se pueda realizar una búsqueda en el archivo y se
pueda copiar texto del documento.

E. Toda comunicación se debe incluir en el SERFF como una “Note to Reviewer”
(Nota al Revisor)” o como una “Response Letter (Carta de Respuesta).”
Cualquier otro tipo de comunicación se tendrá por no recibida.

En vista de estas normas nuevas, por la presente se revoca la Carta Normativa Núm.
2011-128-AV, del 12 de julio de 2011.

Se ordena por la presente el cumplimiento estricto con las disposiciones de esta Carta
Normativa.

Cordialmente,

FIRMADA

Ángela Weyne Roig
Comisionada de Seguros

March 2014
1

Attachment 1

Puerto Rico
Rate Filing Instruction Manual
vista de estas normas nuevas, por la presente se revoca la Carta Normativa Núm.
2011-128-AV, del 12 de julio de 2011.

Se ordena por la presente el cumplimiento estricto con las disposiciones de esta Carta
Normativa.

Cordialmente,

FIRMADA

Ángela Weyne Roig
Comisionada de Seguros

March 2014
1

Attachment 1

Puerto Rico
Rate Filing Instruction Manual

March 2014
2
Overview
This instruction manual supports implementation of the requirement of Ruling Letter NO. CN-
2014-175-AS. For all ACA compliant products, rates for new products and all rate changes must
be submitted to the OCI for approval.
For all grandfathered products only rate increases must be filed with the OCI. Under Section
2794 of the Public Health Service Act, as amended by Section 1003 of the Federal Patient
Protection and Affordable Care Act (“PPACA”), disability insurers that write medical plans in
Puerto Rico have the obligation to submit to the Office of the Commissioner of Insurance
(“OCI”,”OCS”), for review and approval, any rate increase for non-grandfathered plans where
the average increase is equal to or greater than ten percent (10%) of current rates, effective
September 1, 2011. For Health Service Organizations all rate increases must be submitted to
OCI no matter the amount of the increase. The purpose of this requirement is to allow the OCI
(OCS) to determine whether the proposed rate increase for small group and individual markets is
unreasonable. Rates that are subject to approval by the OCI (OCS) must be submitted at least
sixty (60) days before the effective date.1 If there is an objection from the OCI (OCS), the time
required for the objection to be answered will not be included in the 60 days and therefore may
delay the implementation date.
The carrier MUST only use the rates filed and approved.
A complete rate filing must include all of the information required by Ruling Letter NO. CN-
2014-175-AS, as applicable
(60) days before the effective date.1 If there is an objection from the OCI (OCS), the time
required for the objection to be answered will not be included in the 60 days and therefore may
delay the implementation date.
The carrier MUST only use the rates filed and approved.
A complete rate filing must include all of the information required by Ruling Letter NO. CN-
2014-175-AS, as applicable. The manual and templates do not supersede the regulations, they
merely standardize and make explicit the information already required or allowed to be requested
by those regulations.
Carriers must use SERFF to submit their rate filings as required by Ruling Letter 2012 140-AV
of February 7, 2012. Carriers must fill out all the SERFF data elements, including Affordable
Care Act (“ACA”) data elements, or the filing will be rejected as incomplete. ACA requires that
if there is any rate change to an ACA compliant product, rates for all ACA compliant products in
that market (individual or small group) must be filed together. That is if any rates change all
previously filed rates must be filed again with the new rates.
Under the Affordable Care Act and rules that became effective on 9/1/2011, carriers with
average rate increases of more than 10% per year must submit rate justification information to
the Federal Center for Consumer Information and Insurance Oversight (“CCIIO”). For non-
ACA compliant products2, the federal rate summary worksheet and Preliminary Justification also
should be submitted to the Centers for Medicare & Medicaid Services (“CMS”) on the same date
as the filing with the OCI (OCS). Please note that the information submitted to the OCI (OCS)
should be consistent with the information submitted to the “CCIIO” and “CMS.” In Puerto Rico,
all rate increases by HMOs must be filed with the OCI (OCS) if they are ACA compliant or not
ry Justification also
should be submitted to the Centers for Medicare & Medicaid Services (“CMS”) on the same date
as the filing with the OCI (OCS). Please note that the information submitted to the OCI (OCS)
should be consistent with the information submitted to the “CCIIO” and “CMS.” In Puerto Rico,
all rate increases by HMOs must be filed with the OCI (OCS) if they are ACA compliant or not.

1 To ensure that rates are approved before they are effective the OCI is requesting that all rates be filed 90 days
before they are used. This will be May 30, 2014 for rate filings for 2015 rates.
2 Non-ACA compliant policies include grandfathered policies and transitional policies.

March 2014
3
Consistent with ACA, the OCI (OCS) requires rate filings to include the following parts, if there
is any change in rates or plans offering of ACA compliant products in a market. For all ACA
compliant products the following should be filed once a year even if there is no rate change. For
ACA compliant products and all grandfathered HMO rate increases and non-HMO rate increases
over 10% should also submit the following:
1) Federal Rate Review Justification Part I: Unified Rate Review Template (URRT);
2) Public form of the rate filing information to be placed on the OCI (OCS) website and
used for the HIOS Federal Rate Review Justification Part II: Written explanation of any
rate increase that is 10% or over;
3) Actuarial Memorandum meeting the requirements of Puerto Rico and the federal 2014
Actuarial Memorandum and Certification Instructions 2.0 (Part III).
4) Puerto Rico actuarial certification;
5) Actuarial value calculator screenshots (for ACA compliant only);
6) SERFF Rate template;
7) Rate manual
8) Puerto Rico Benefits Map (if different from the Benefits Map already filed with the OCI
(OCS) or not Benefits Map has been filed; and
9) Rate filing checklist (see Appendix A: Rate Filing Checklist)
d Certification Instructions 2.0 (Part III).
4) Puerto Rico actuarial certification;
5) Actuarial value calculator screenshots (for ACA compliant only);
6) SERFF Rate template;
7) Rate manual
8) Puerto Rico Benefits Map (if different from the Benefits Map already filed with the OCI
(OCS) or not Benefits Map has been filed; and
9) Rate filing checklist (see Appendix A: Rate Filing Checklist).
Section I: Unified Rate Review Template (URRT)
Provide a copy of the URRT template in Excel and also in a PDF printout version. The URRT
should be completed with all HIOS information.
For a more complete description of the items in the URRT, please refer to the Department of
Health and Human Services (HHS) instructions.
Section II: Written Explanation
For all rate increases that are greater than the review threshold, a brief written explanation of the
rate increase must be submitted. This written explanation must include a simple and brief
narrative describing the data and assumptions that were used to develop the rate increase. This
includes:
1) Brief description in simple language the reasons why the rate increase is being requested;
2) Explanation of the most significant factors causing the rate increase, including a brief
description of the relevant claims and non-claims expense increase reported in the rate
increase summary; and
3) Brief description of the overall experience of the policy, including historical and
projected expenses, and loss ratios.
This summary will be uploaded to the OCI website for public use and it will also be used for the
HIOS Preliminary Justification Part II that is required for all rate increases over 10%.
t claims and non-claims expense increase reported in the rate
increase summary; and
3) Brief description of the overall experience of the policy, including historical and
projected expenses, and loss ratios.
This summary will be uploaded to the OCI website for public use and it will also be used for the
HIOS Preliminary Justification Part II that is required for all rate increases over 10%.

March 2014
4
Section III: Federal Actuarial Memorandum and Certification3
The Actuarial Memorandum and Certification documents the methodology used in developing
the rates and includes an actuarial opinion signed by a qualified actuary providing an opinion
that the rate filing was developed according to actuarial standards and principles and the laws of
Puerto Rico.
A Part III Federal Actuarial Memorandum, including a corresponding actuarial certification,
must be submitted with each Part I Unified Rate Review Template.
The purpose of the Part III actuarial memorandum is to provide support for the values entered
into the Part I Unified Rate Review Template. The documentation should clearly identify the
plans applicable to each piece of information. All assumptions should be adequately justified
with supporting data, where possible, and the rationale for the use of the chosen assumptions.

For a more complete description of the items in the Part III Actuarial Memorandum and
Certification, please refer to the Department of Health and Human Services (HHS) instructions.
Section IV: Puerto Rico Actuarial Memorandum
In order to review rates in Puerto Rico the OCI requires information in addition to the federal
actuarial memorandum. We encourage carriers to submit both the federal information and the
additional Puerto Rico information in the same document. Information that we believe to be in
addition to the federal requirements is italicized below. This difference may change in the future
as the federal requirements change
tes in Puerto Rico the OCI requires information in addition to the federal
actuarial memorandum. We encourage carriers to submit both the federal information and the
additional Puerto Rico information in the same document. Information that we believe to be in
addition to the federal requirements is italicized below. This difference may change in the future
as the federal requirements change.
The carrier must provide a detailed description of the method used to develop the premium rates.
Since there is much overlap with the Federal Actuarial Memorandum, one actuarial
memorandum can be submitted as long as it contains all of the information required in both
memorandums. The major difference is the Puerto Rico requirements is the addition of
quantitative support for assumptions. The memorandum should also include more detail on any
item that the carrier believes is driving the rate increase projections or would be of particular
concern when reviewing the rate filing.
Overview of Rate Increase
Provide a brief explanation of why a rate increase is being requested and on what policy forms
including the names of the policy forms affected.
Describe the scope and driving factors impacting the rate increase including a description of how
the rates were determined.
Provide a description of:
1) Type of Products;
2) Benefits;
3) General Marketing Method;

3 See Appendix B for Actuarial Certification
what policy forms
including the names of the policy forms affected.
Describe the scope and driving factors impacting the rate increase including a description of how
the rates were determined.
Provide a description of:
1) Type of Products;
2) Benefits;
3) General Marketing Method;

3 See Appendix B for Actuarial Certification

March 2014
5
4) Premium Classifications or Rating Factors; and
5) Underwriting Method (grandfathered only).
Rate increase information including:
1) Historic rate increases for the last 3 years;
2) Proposed effective date of the rate increase (grandfathered only);
3) Requested minimum, maximum and average rate increase – from current rates and
annual from one year prior; and
4) Effective through date and any rate increase schedule applicable (small group only).4
Base Period Experience
Provide an explanation of the base period experience used indicating the basis of the data used,
the first incurred date included and the last incurred date included. The last paid date used should
be provided, which indicates the paid through date for the base period experience.
Provide an explanation of how incurred claims were estimated from paid claims including the
average completion factor5 used and an explanation of adjustments made to base period claims
experience.
If contract reserves were established for these contracts, describe what they are for, how they
were developed and how they impacted the rate development.
Describe the treatment of large claims and claims pooling, if any.
Treatment of commercial reinsurance, if any. This is separate from the Transitional Federal
Reinsurance program, but is adjustments for commercial reinsurance purchased by the carrier
to protect against the risk of large claims.
Provide an exhibit showing current age distribution and the age distribution anticipated for
projection period, if different
large claims and claims pooling, if any.
Treatment of commercial reinsurance, if any. This is separate from the Transitional Federal
Reinsurance program, but is adjustments for commercial reinsurance purchased by the carrier
to protect against the risk of large claims.
Provide an exhibit showing current age distribution and the age distribution anticipated for
projection period, if different.
Capitation Payments
Describe what is covered by any capitation payments and the PMPM impact.
Projection Factors and Claims Trends
Provide documentation of all assumptions and methodologies used in the development of the
impact of morbidity and enrollee mix.
If there were changes in the benefits covered, provide a description of all benefit changes and
quantitative support of their impact.

4 Small group rate increases can only be on a quarterly basis.
5 The average completion factor is the ratio of the incurred claims for a period of time to the paid claims for the
same period as of the last paid date used for the base period experience. The incurred claims are the total claims
that are expected to be paid in the base experience. The paid claims are the amounts that have actually been paid as
of any point in time. As time goes on more claims are paid and the ratio is higher.

March 2014
6
For each Essential Health Benefit (EHB) not covered previously, the additional cost per-
member-per-month (PMPM) with an actuarial explanation of how the additional cost was
developed.
Provide a description of all changes in the rating structure, if any, and provide quantitative
support of their impact including all assumptions used.
Provide quantitative support of the impact due to changes to network, if any.
If there are other changes impacting rates, provide a description and quantitative documentation
of all factors, including any adjustments for past experience due to actual loss ratios differing
from target loss ratios
tructure, if any, and provide quantitative
support of their impact including all assumptions used.
Provide quantitative support of the impact due to changes to network, if any.
If there are other changes impacting rates, provide a description and quantitative documentation
of all factors, including any adjustments for past experience due to actual loss ratios differing
from target loss ratios.
Provide quantitative documentation of the trend development including as well as an explanation
of the data, assumptions, and periods used.
Provide:
 Changes in medical cost trend by major service categories for the past three years and
future projections.
 Changes in the use of services by major service categories for the past three years and
future projections.
Historic cost and utilization assumptions used compared to the actual trends experienced. Until
2015 filings for the 2016 rates, there may be little or no information, but starting in 2015 you
should provide the past projections compared to the actual experience.
Please explain significant changes in assumptions from the prior filing assumptions.
Manual Rate Development
If the experience for the product is too small to be considered credible, alternative claims
experience can be used. Include detail description of all alternative experience data used and
how it was adjusted to be appropriate for the market including any adjustments similar in type to
the adjustments made to base data.
Credibility
Indicate the credibility methodology and credibility level of the base period experience.
Paid to Allowed Ratio
Provide a quantitative demonstration of the development of the paid to allowed ratio.6 Since
Puerto Rico has different claims distribution patterns than those used as the basis of the AVC, it
has been determined that company specific projections, which will not be similar to the AVC
outputs, should be used for Puerto Rico rate development and in the URRT Market Experience
worksheet cell V33
Provide a quantitative demonstration of the development of the paid to allowed ratio.6 Since
Puerto Rico has different claims distribution patterns than those used as the basis of the AVC, it
has been determined that company specific projections, which will not be similar to the AVC
outputs, should be used for Puerto Rico rate development and in the URRT Market Experience
worksheet cell V33. 7

6 This ratio is actually the incurred claims to allowed claims ratio
7 The AVC should be used for the determination of metal levels unless it is replaced by a Puerto Rico specific
calculator

March 2014
7
Risk Adjustment and Reinsurance
Risk adjustment and reinsurance do not apply to Puerto Rico.
Non-Benefit Expense Projections
The methodology used to project non-benefit expenses, including gain/loss margins, should be
explained. If a loss ratio approach was used, the carrier should explain how the target loss ratio
was developed.
Administrative Costs
Identify the main factors that affect changes in administrative costs. Discuss how changes in
projected administrative costs and profit are impacting the rate increase and what is driving
these changes.
If budgets were used, the carrier should explain when the budgets were developed and for what
time period.
Provide actual administrative expenses PMPM for the last three years and explain any
significant changes in administrative expenses from the prior filing.
Provide a breakdown of projected administrative expenses with any marketing, commission, and
quality improvement costs separated. If there are no quality improvement costs in the
administrative costs, indicate zero.
If administrative expenses vary by plan explain why.
Projected Gain/Loss Margins
Provide an explanation of how the projected gain/loss margins were developed and any changes
from prior filings
kdown of projected administrative expenses with any marketing, commission, and
quality improvement costs separated. If there are no quality improvement costs in the
administrative costs, indicate zero.
If administrative expenses vary by plan explain why.
Projected Gain/Loss Margins
Provide an explanation of how the projected gain/loss margins were developed and any changes
from prior filings.
Taxes and Fees
Provide a description of applicable taxes and fees, their impacts, and an explanation of how they
were allocated across plans.
Provide a breakdown of projected taxes with amounts of each and their quantitative
development.
Medical Loss Ratio
Describe how the projected federal medical loss ratio was calculated. Describe how the
credibility adjustment was determined. A demonstration of the projected loss ratio using the
federal loss ratio formula should be provided including the values used.
If the loss ratio is less than the federal rebate requirement, explain the plan to xomply with the
Federal MLR requirement.
Index Rate
This documentation should provide a descriptive and quantitative development of the plan index
rates starting with the market index. This development should be supported by excel exhibits
with formulas intact. The following steps should be explicit:

March 2014
8
1) Plan level adjustments
a. Projected ratio of incurred claims to allowed claims (pricing actuarial value) for
each plan and any adjustment to utilization due to cost sharing (separate, if
possible);
b. Provider network, delivery system and utilization management adjustment;
c. Benefits in addition to EHBs (the estimate of these benefits should be shown in a
quantitative development);
d. Impact of the eligibility for the catastrophic plan; and
e. Administrative costs.
2) Calibration for base characteristics to base market allowed:
a. Weighted average age;8
b. Calibration for family composition;9, and
c
k, delivery system and utilization management adjustment;
c. Benefits in addition to EHBs (the estimate of these benefits should be shown in a
quantitative development);
d. Impact of the eligibility for the catastrophic plan; and
e. Administrative costs.
2) Calibration for base characteristics to base market allowed:
a. Weighted average age;8
b. Calibration for family composition;9, and
c. Calibration for tobacco usage.10
Provide quantitative documentation of the rating factor for tobacco.
Provide an example procedure of determining a family rate. Demonstrate that this family rating
complies with the federal rating rules of the ACA.
AV Metal Values
The AV Metal Values must be determined using the Federal Actuarial Value Calculator. If an alternative
methodology was used due to a unique plan design, it must be well documented.
Plan Adjusted Index Rate
Provide quantitative development in excel with all formulas of the plan adjusted index rate. This
development should start with the market index rate and show all adjustments in the development of the
plan adjusted index rate. The plan adjusted index rate divided by the average age factor should result in
the plan base rate (age 21 non-tobacco rate).
Membership
Provide documentation of all assumptions used to project membership and provide support for those
assumptions.
Company Financial Condition
Describe the financial situation of the company, including surplus, if any. Provide 5 years of
RBC ratio levels.

8 The federal instructions only ask for a weighted average age, but we are requesting the calibration factor, which
is typically the inverse of the weighted average age factor.
9 This calibration is for the situation where there are more than three children, but only three can be included in
the premium.
10 At this time we believe that the federal instructions will be to add this calibration to the actuarial value
adjustment, but we would like to see it separated out.
uesting the calibration factor, which
is typically the inverse of the weighted average age factor.
9 This calibration is for the situation where there are more than three children, but only three can be included in
the premium.
10 At this time we believe that the federal instructions will be to add this calibration to the actuarial value
adjustment, but we would like to see it separated out.

March 2014
9
Provide historic loss ratios for the last five years.
Small Groups Affected
The carrier should provide a list of all small groups affected by the proposed rate increase, the
proposed increase for each group, the date of the group’s contract renewal, and the effective
date for each group 30 days prior to implementation. The list of small groups affected and
renewal dates will depend on the proposed effective date of the rate increase. The carrier should
list all small groups that will receive a rate increase in the next 30 day period with each group’s
average rate increase, renewal date and rate increase effective date in an Excel file attached to
an email to the OCI. This information will eventually be posted to the OCI website.
Section V: Public Information
Every carrier must provide a written summary of the rate filing to be displayed on the OCI
(OCS) public website. For rate increases over 10% this will also serve as the Preliminary
Justification Part II that should be uploaded to HIOS.
Section VI: Rate Template
Provide the federal SERFF Rates Template in excel. This may need to be uploaded in a zip file if
they are too large to upload to SERFF.
Section VII: Benefits Map and Actuarial Value
Every carrier should provide to the OCI a benefits map which shows, for all plans, all benefits
covered and their respective cost sharing amounts and limits. If the benefits map for a plan has
not changed from the prior filing, it does not need to be resubmitted
his may need to be uploaded in a zip file if
they are too large to upload to SERFF.
Section VII: Benefits Map and Actuarial Value
Every carrier should provide to the OCI a benefits map which shows, for all plans, all benefits
covered and their respective cost sharing amounts and limits. If the benefits map for a plan has
not changed from the prior filing, it does not need to be resubmitted. The carrier should submit a
list of plans with an indication of which Benefits Maps are included and the date submitted for
any that were submitted previously.
Also for all plans, screenshots of the federal Actuarial Value Calculator (AVC) populated with
plan cost share information should be submitted. If the plan has a unique plan design that does
not work with the federal Actuarial Value Calculator, a certification of unique plan should be
submitted to the OCI as well as quantitative documentation of all adjustments and explanation of
all differences that could not be accommodated using the AVC . If the plan decides not to use the
AVC, they should provide a certification of unique plan design, an explanation of why they did
not use the AVC, and quantitative support for the calculation of each plan’s actuarial value.
If several plans are offered at the same metal level in the same region, the sponsor should
provide further information on them describing what differentiates them and what the target
market is for each.
Section VIII: Rate Manual
If the rate manual has changed or if a carrier has a new product, it should file the rate manual
with the OCI.
the calculation of each plan’s actuarial value.
If several plans are offered at the same metal level in the same region, the sponsor should
provide further information on them describing what differentiates them and what the target
market is for each.
Section VIII: Rate Manual
If the rate manual has changed or if a carrier has a new product, it should file the rate manual
with the OCI.

March 2014
10
Appendix A - Rate Filing Checklist
Carrier Name:

Date of Initial Filing:

Is this Original or Replacement:

NAIC Company Code:

SERFF Tracking Number:

Market:

For OCI Use Only

Item
File name and
page or
worksheet
Carrier verified
complete filing
(initial)
Complies
Does not
Comply
Comments
Unified Rate Review Template (Excel and PDF)

Public Form of the Rate Filing Information to be
Placed on the OCI website (For Increases Greater
than 10% this will be the Preliminary Justification
Part II)

Brief description in simple language the reasons why the
rate increase is being requested.

Explanation of the most significant factors causing the
rate increase, including a brief description of the relevant
claims and non-claims expense increases reported in the
rate increase summary

Brief description of the overall experience of the policy,
including historical and projected expenses, and loss
ratios.

Actuarial Memorandum meeting the requirements
of Puerto Rico and the Federal 2014 Actuarial
Memorandum and Certification Instructions 2.0
(Part III)

General Information

Company legal name

HIOS issuer ID
scription of the overall experience of the policy,
including historical and projected expenses, and loss
ratios.

Actuarial Memorandum meeting the requirements
of Puerto Rico and the Federal 2014 Actuarial
Memorandum and Certification Instructions 2.0
(Part III)

General Information

Company legal name

HIOS issuer ID

March 2014
11
Market

Effective date

Primary contact name, telephone number, email address

Overview of Rate Increase

Provide a brief explanation of why a rate increase is being
requested and on what policy forms including the names
of the policy forms affected.

Describe the scope and driving factors impacting the rate
increase including a description of how the rates were
determined.

Overview of products. This should be a description of
type of products, benefits, marketing method, premium
classifications, renewability, and underwriting method.

Historical rate increase for last 3 years.

Rate increase detailed information such as averages,
minimum and maximum

Effective through date and any rate increase schedule
applicable (small group only)

Include all products which are part of the single risk pool,
including those with no proposed rate adjustment

Base Period Experience

Explanation of the base period used indicating the basis
of the data used, first and last incurred date included.

Indicate paid through date

Provide support for the development of the actuary's best
estimate of allowed and paid claims incurred during the
experience period

Describe the treatment of large claims and claims
pooling, if any.

Treatment of commercial reinsurance, if any
basis
of the data used, first and last incurred date included.

Indicate paid through date

Provide support for the development of the actuary's best
estimate of allowed and paid claims incurred during the
experience period

Describe the treatment of large claims and claims
pooling, if any.

Treatment of commercial reinsurance, if any. This is
separate from the Transitional Federal Reinsurance
program, but is adjustments for commercial reinsurance
purchased by the carrier to protect against the risk of
large claims.

Indicate the amount of MLR rebates refunded during
experience period

March 2014
12
Exhibit showing current age distribution with those
anticipated for projection period

Capitation Payments

Describe what is covered by any capitation payments.

Projection Factors

Provide documentation of all assumptions and
methodologies used in the development of the impact of
morbidity and enrollee mix.

If there were changes in the benefits covered, provide a
description of all benefit changes and quantitative support
of their impact.

For each Essential Health Benefit (EHB) not covered
previously, the additional cost per-member-per-month
(PMPM) with an actuarial explanation of how the
additional cost was developed.

For adjustment factors related to differences in
demographics, if applicable, include a description of the
source data or assumptions used, why they are
appropriate for the single risk pool, and any applicable
adjustments made to the data, such as considerations for
issuer specific experience, industry or internal studies,
benefit design and credibility.

If there are other changes impacting rates, provide a
description and quantitative documentation of all factors
scription of the
source data or assumptions used, why they are
appropriate for the single risk pool, and any applicable
adjustments made to the data, such as considerations for
issuer specific experience, industry or internal studies,
benefit design and credibility.

If there are other changes impacting rates, provide a
description and quantitative documentation of all factors.

Provide a description of all changes in the rating
structure, if any, and provide quantitative support of their
impact including all assumptions used.

Provide quantitative support of the impact due to changes
to network, if any.

Provide quantitative documentation of the trend
development including as well as an explanation of the
data, assumptions, and periods used.

Changes in medical cost trend by major service categories
for the past three years and future projections.

Changes in the use of services by major service
categories for the past three years and future projections.

Please explain significant changes from the prior filing
assumptions.

March 2014
13
Manual Rate Development, if applicable

Describe the source data used to develop the manual rate
and why such data is appropriate.

Describe all adjustments made to the data underlying the
development of the manual rate to account for differences
in demographics, benefits and morbidity/risk to ensure
that that resulting manual rate is appropriate for blending
with the adjusted experience period claims.

Credibility

Indicate the credibility methodology and credibility level
of the base period experience.

Paid to Allowed Ratio

Provide a quantitative demonstration of the development
of the paid to allowed ratio based on company specific
projections
manual rate is appropriate for blending
with the adjusted experience period claims.

Credibility

Indicate the credibility methodology and credibility level
of the base period experience.

Paid to Allowed Ratio

Provide a quantitative demonstration of the development
of the paid to allowed ratio based on company specific
projections.

Non-Benefit Expense Projections

Administrative Costs

The methodology used to project administrative
expenses, including gain/loss margins, should be
explained.

Identify the main factors that affect changes in
administrative costs. Discuss how changes in projected
administrative costs are impacting the rate increase and
what is driving these changes.

Actual administrative expenses PMPM for the last three
years and explain any changes in administrative expenses
from the prior filings.

Breakdown of projected administrative expenses with any
quality improvement costs separated.

Discuss how and why the percentage administrative load
varies by product or plan, if applicable

Projected Gain/Loss Margins

Describe the target underwriting gain/loss margin, and
any additional risk margin

To the extent that the target as a percent of premium has
changed from the prior submission, provide additional
support for why the change is warranted
ercentage administrative load
varies by product or plan, if applicable

Projected Gain/Loss Margins

Describe the target underwriting gain/loss margin, and
any additional risk margin

To the extent that the target as a percent of premium has
changed from the prior submission, provide additional
support for why the change is warranted

March 2014
14
Discuss how the percentage load varies by product or
plan, if applicable

Taxes and Fees

Describe each tax and/or fee and indicate the amount for
each, either as a percent of premium or a PMPM amount
and a quantitative development.

Provide an explanation of how taxes and fees were
allocated across plans.

Medical Loss Ratio

Provide a demonstration of the projected loss ratio using
the federal rebate loss ratio formula including the values
used.

Describe how the credibility adjustment was determined,
if applicable.

If the projected loss ratio is less than federal requirement,
explain the plan to comply with the Federal MLR
requirement.

Index Rate

Demonstrate in Excel with formulas how the projected
market level index rate was adjusted to arrive at each plan
level index rate.

Provide an example procedure of determining a family
rate. Demonstrate that this family rating complies with
the federal rating rules of the ACA
explain the plan to comply with the Federal MLR
requirement.

Index Rate

Demonstrate in Excel with formulas how the projected
market level index rate was adjusted to arrive at each plan
level index rate.

Provide an example procedure of determining a family
rate. Demonstrate that this family rating complies with
the federal rating rules of the ACA.

For the catastrophic plan rate, describe the methodology
used to estimate the adjustment reflecting differences in
anticipated demographics and morbidity of the
catastrophic population as compared to the single risk
pool

AV Metal Values

The issuer must describe whether the AV Metal Values
included were entirely based on the AV Calculator, or
whether an acceptable alternative methodology was used
to generate the AV Metal Value of one or more plans

If an alternate methodology was employed to develop the
AV Metal Value(s), the actuary must provide a copy of
the actuarial certification required by 45 CFR Part 156,
§156.135

March 2014
15
Provide all AVC screen shots

Plan-Adjusted Index Rate

Quantitative development in Excel (with working
formulas) of the plan-adjusted index rates starting with
the market index rate.

Membership Projections

Describe how the membership projections were
developed

Describe any differences between the distribution of
projected member months relative to the current
membership distribution

Company Financial Condition

Describe the financial situation of the company, including
surplus, if any. Provide 5 years of RBC ratio levels.

Provide historic loss ratios
membership projections were
developed

Describe any differences between the distribution of
projected member months relative to the current
membership distribution

Company Financial Condition

Describe the financial situation of the company, including
surplus, if any. Provide 5 years of RBC ratio levels.

Provide historic loss ratios.

Terminated Products

List the name of each product that will be terminated
prior to the effective date including other products that
have experience included in the single risk pool during
the experience period and any products that were not in
effect during the experience but were made available
thereafter

Plan Type

In the event that the plan types listed in the drop-down
box in Worksheet 2, Section I of the Part I Unified Rate
Review Template do not describe an issuer’s plan exactly
and the issuer has selected the closest plan available, per
the instructions, please describe the differences between
the issuer’s plan and the plan type selected.

Warning Alerts

Describe any difference between the sum of the plan level
projections and the total projected amounts

Reliance

If the certifying actuary relied on any information or
underlying assumptions provided by another individual,
the information relied upon and the name of the
plan and the plan type selected.

Warning Alerts

Describe any difference between the sum of the plan level
projections and the total projected amounts

Reliance

If the certifying actuary relied on any information or
underlying assumptions provided by another individual,
the information relied upon and the name of the

March 2014
16
individual providing that information may be disclosed.
For All Small Groups Affected

Name of group

Group's average rate increase

Date of contract renewal

Effective date of rate increase

Federal Actuarial Certification

Puerto Rico Certification Letter

SERFF Rates Template (Excel)

Rating Manual (if filed previously indicate date
filed)

Puerto Rico Benefits Maps for each plan (if filed
previously indicate date filed)

COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE

B5 Tabonuco Street, Suite 216 • PMB 356 • Guaynabo, PR 00968-3029
Phone: (787) 304-8686 • Fax: (787) 273-6082
www.ocs.gobierno.pr

17
Appendix B – Standardized Actuarial Certification Letter

Certification

Standardized Excel Worksheet/Written Filing Documentation/Rate Manual

I _________________________________________ hereby certify that I was in charge of the preparation, revision or supervision of the
worksheet data information corresponding to the submitted rate increase filing. In addition, I certify that the submitted information is
accurate, true and complete.

I also acknowledge responsibility for the validity, accuracy and completeness of the contents of the Written Filing Documentation and the
Rate Manual.

______________________________
Signature

______________________________
Title

______________________________
Carrier

______________________________
Date
, I certify that the submitted information is
accurate, true and complete.

I also acknowledge responsibility for the validity, accuracy and completeness of the contents of the Written Filing Documentation and the
Rate Manual.

______________________________
Signature

______________________________
Title

______________________________
Carrier

______________________________
Date

1

Attachment 2

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-15
Baltimore, Maryland 21244-1850

Part I Unified Rate Review Template Instructions

February 3, 2014

2

Part I Unified Rate Review Template v2.0.1

The Part I Unified Rate Review template is required to be submitted by all issuers in the
individual, small group and/or combined markets that are proposing a rate increase on any
single risk pool compliant products. In addition, all issuers applying to offer at least one QHP in
the state must submit the template for the market in which the QHP would be offered. The
template may also be required by regulatory authority for products in the single risk pool.
Issuers are required to submit the annual rate change (i.e. January rate changes). In addition,
quarterly rate increases for the small group market are allowed if allowed by the state
regulatory authority. See the Appendix for additional detail on the timeframe for submission.

All issuers are required to set the Index Rate for an effective date of January 1 of each year, and
file the Index Rate with the applicable regulatory authority. Subject to state requirements, small
group issuers are allowed to file subsequent submissions that reset the Index Rate for the
remaining quarters of the calendar year
Appendix for additional detail on the timeframe for submission.

All issuers are required to set the Index Rate for an effective date of January 1 of each year, and
file the Index Rate with the applicable regulatory authority. Subject to state requirements, small
group issuers are allowed to file subsequent submissions that reset the Index Rate for the
remaining quarters of the calendar year.

The Part I Unified Rate Review template is intended to:

• Demonstrate compliance with the Single Risk Pool requirement of 45 CFR Part 156.80,

• Provide support for the development of the Index Rate which is defined in 45 CFR Part
156.80(d),

• Identify product level rate increases to determine whether a rate increase is subject to
review under 45 CFR Part 154, and

• Provide supporting information to State or Federal regulators for product level rate
increases

Additional information about how CCIIO uses or discloses information from the template is
described in the Appendix.

Specific instructions for the treatment of dental plans within the Part I Unified Rate Review
template have been developed for plans offered in 2015 and beyond.

• Only embedded pediatric dental benefits within a medical plan should be reflected in
the Part I Unified Rate Review Template. Further, in order for the dental costs to be
included in the Part I Unified Rate Review Template the dental costs must be spread
across the entire single risk pool in accordance with the market rating rules in
calculating the projected Index Rate.
2015 and beyond.

• Only embedded pediatric dental benefits within a medical plan should be reflected in
the Part I Unified Rate Review Template. Further, in order for the dental costs to be
included in the Part I Unified Rate Review Template the dental costs must be spread
across the entire single risk pool in accordance with the market rating rules in
calculating the projected Index Rate.

3

• Under no circumstances should stand‐alone dental plans be reflected in the Part I
Unified Rate Review Template.

Further details explaining how dental plans should be reflected in the template can be found in
the instructions for Worksheet 2.

Beginning with plans effective in 2015 and beyond, ALL benefits to be offered in a plan must be
included in that plan. So if an issuer wants to offer an “optional” benefit, there are two options
an issuer can use to meet this goal.

• The issuer can create a separate plan with the required EHBs and the “optional” benefit
included.

• The issuer can offer a separate policy which is a supplemental policy providing non‐EHB
benefits.

The concept of “optional riders” is incongruent with federal rating rules and the single risk pool
requirements.

It is critically important that information be entered into the template as accurately as possible
with the information available to the issuer at the time of submission. Failure to provide
accurate information in the first submission increases the likelihood of the need to provide
additional data to the State or Federal regulators reviewing the template. Failure to provide
accurate information also slows the speed of any required approvals or certification and puts
the products and plans at risk for missing critical deadlines to be offered in the markets
sion. Failure to provide
accurate information in the first submission increases the likelihood of the need to provide
additional data to the State or Federal regulators reviewing the template. Failure to provide
accurate information also slows the speed of any required approvals or certification and puts
the products and plans at risk for missing critical deadlines to be offered in the markets.

Beware, if an issuer copies and pastes values into cells that do not match the formatting
requirements of those cells, the mismatch may cause validation or submission errors resulting
in either submissions being rejected or requiring resubmissions at a later date. Issuers should
verify the data entered in the Part I Unified Rate Review Template is consistent with formatting
requirements and instructions to avoid delays in the approval process.

Under no circumstances should issuers attempt to overwrite protected cells. For example, the
totals in column F of Worksheet 2 are protected and calculated by formula. Issuers should not
attempt to overwrite the values calculated by the template. Any overwriting of the workbook’s
protection is likely to result in delays and resubmissions.

The following should be considered an instructional tool in developing issuer pricing, as allowed
under the market and rating rules for the single risk pool.

ACA & MARKET RATING RULES ‐ ALLOWABLE RATING & PRICING

Allowable rating methods and factors
write the values calculated by the template. Any overwriting of the workbook’s
protection is likely to result in delays and resubmissions.

The following should be considered an instructional tool in developing issuer pricing, as allowed
under the market and rating rules for the single risk pool.

ACA & MARKET RATING RULES ‐ ALLOWABLE RATING & PRICING

Allowable rating methods and factors

4

• The Single Risk Pool should include ALL (non‐grandfathered) covered persons (lives) an
issuer has in a state, within a market (individual, small group or combined).  This
includes transitional products/plans for purposes of base period experience used to
demonstrate the single risk pool. The projection period should reflect experience of
transitional policies to the extent the issuer anticipates the members in those policies
will be enrolled in fully ACA‐compliant plans during the projection period.

• The Index Rate is defined as the EHB portion of projected allowed claims divided by all
projected single risk pool lives. As a result, the Index Rate should be the same value for
ALL non‐grandfathered plans for an issuer in a state and market. This includes claims
and enrollment in transitional products/plans in the experience period, and in the
projection period to the extent the issuer anticipates the members in those policies will
be enrolled in fully ACA‐compliant plans during the projection period. Note that if an
issuer opted to continue policies under the President’s transitional memorandum,
experience for these policies should be included in the issuer’s 2013 experience for
developing rates for the 2015 year. Appropriate adjustments should be made in
Worksheet 1 – Section II of the Unified Rate Review Template to bring these policies in
line with all requirements of non‐grandfathered policies projected in the Single Risk Pool
in 2015
nder the President’s transitional memorandum,
experience for these policies should be included in the issuer’s 2013 experience for
developing rates for the 2015 year. Appropriate adjustments should be made in
Worksheet 1 – Section II of the Unified Rate Review Template to bring these policies in
line with all requirements of non‐grandfathered policies projected in the Single Risk Pool
in 2015. For example, in the projection period, include projected experience and
membership at the point when these products become ACA‐compliant and the
membership renews to the ACA‐compliant plan, or at the point when the members in
these plans move to an ACA‐compliant plan, if the plans are closed to new membership
in 2015.

• The Market Adjusted Index Rate is the Index Rate adjusted for Risk Adjustment,
Reinsurance and Exchange Fees (with impacts and costs spread across the whole risk
pool). As a result, the Market Adjusted Index Rate should be the same value for ALL
non‐grandfathered plans for an issuer in a state and market.

• The Plan Adjusted Index Rate is the Market Adjusted Index Rate further adjusted for
plan specific factors allowed by 45 CFR Part 156.80(d)(2) such as provider network,
utilization management, benefits in addition to Essential Health Benefits (EHBs),
actuarial value and cost sharing, distribution and administrative costs (less Exchange
fees) and catastrophic plan eligibility variation.

• Note, fees and costs are included in the premium and applied at the plan level as part of
the distribution and administrative costs adjustment. The only exception is the
application of the Exchange User fees, which are applied at the market level to the Index
Rate. All other fees must be included in the development of the Plan Adjusted Index
nd catastrophic plan eligibility variation.

• Note, fees and costs are included in the premium and applied at the plan level as part of
the distribution and administrative costs adjustment. The only exception is the
application of the Exchange User fees, which are applied at the market level to the Index
Rate. All other fees must be included in the development of the Plan Adjusted Index

5

Rate, prior to the application of member level rating factors, such as age factors. No
additional fees may be charged outside of the development of the Plan Adjusted Index
Rate. For example, if it costs an issuer $35 to process an application, that cost must be
included in the premium rate development of all policies (new issues and renewals) and
subject to the member level rating factors such as age and geographic region factors.
The issuer may not, in that example, charge a $35 fee per policy for submission of the
application.

• A calibration may be required to allow the rating factors to be directly applied in order
to generate the Consumer Adjusted Premium Rates.

For each allowable rating factor (i.e. age, geography, and tobacco) there is ONLY ONE
calibration allowed. That is, the calibration from the single risk pool to the allowable
rating factors may not vary by plan; it must be a common adjustment for all plans in a
state and market. The only allowable consumer level premium rate modifiers that can
be calibrated are age, geography and tobacco.

The calibration with respect to the age curve is allowed and identifies the value on the
age curve associated with the weighted average age on the standard age curve. The Plan
Adjusted Index Rate and the age curve can then be used to generate the schedule of
premium rates for all ages for each plan. Calibration may be required for the geographic
factors and tobacco factors. More detailed instructions are provided later in this
document regarding the requirements for the calibration
ge curve associated with the weighted average age on the standard age curve. The Plan
Adjusted Index Rate and the age curve can then be used to generate the schedule of
premium rates for all ages for each plan. Calibration may be required for the geographic
factors and tobacco factors. More detailed instructions are provided later in this
document regarding the requirements for the calibration.

It is important to note that the calibration process (described above) should ONLY occur
after the Plan Adjusted Index Rate has been determined, not at any point before. The
cost of all benefits (EHB and non‐EHB) and other expenses may not be charged to the
consumer using a flat dollar amount. All components under the plan must be part of the
premium charged. All components of the premium are subject to the consumer level
rating adjustments and therefore all components of the premium should likewise have
the calibration applied to them.

The result of this calibration process should be that the Plan Adjusted Index Rate
calibrated for geography and tobacco (but not age), multiplied by the geographic factor
for a given region should be similar to the Premium Rate for that particular plan for a
non‐tobacco user in the given geographic region for the weighted average age (rounded
to a whole number) of the projected single risk pool.

• The Consumer Adjusted Premium Rate is the final premium rate for a plan that is
charged to an individual, family, or small employer group utilizing the rating and
premium adjustments as articulated in the applicable Market Reform Rating Rules.  The
Consumer Adjusted Premium Rate is developed by calibrating the Plan Adjusted Index
Rate to the age curve as described above, calibrating for geography and tobacco if
ed Premium Rate is the final premium rate for a plan that is
charged to an individual, family, or small employer group utilizing the rating and
premium adjustments as articulated in the applicable Market Reform Rating Rules.  The
Consumer Adjusted Premium Rate is developed by calibrating the Plan Adjusted Index
Rate to the age curve as described above, calibrating for geography and tobacco if

6

necessary, and applying the allowable rating factors. Allowable rating factors are Age
(3:1 standard age curve or state specific age curve), Tobacco, Geography and Family
tiering/structure, unless otherwise prohibited by state law.

Once the Plan Adjusted Index Rate is calibrated to the age curve using the weighted
average age, the entire set of age rates is determined using the standard age factor of
each age relative to the standard age factor for the rounded weighted average age. The
age factors must be the standard age curve set by HHS or a state specific age curve (if
the state requires different age factors than the standard federal age curve).

The tobacco factors can be issuer specific but cannot vary by product/plan for an issuer
(i.e. an issuer must use the same tobacco factors across all products/plans within a state
and market).

Geographic rating areas are set specific to each state and all issuers in the state are
required to follow them and may only set one rating factor per rating area per state per
market and that factor is applied to all plans the issuer has in that rating area
uniformly.  If an issuer has multiple networks within a given rating area and wants to
develop premiums specific for each network, the issuer must have a separate plan for
each network with the rating area.

Family structure takes into account family composition and the maximum of 3 child
dependents
state per
market and that factor is applied to all plans the issuer has in that rating area
uniformly.  If an issuer has multiple networks within a given rating area and wants to
develop premiums specific for each network, the issuer must have a separate plan for
each network with the rating area.

Family structure takes into account family composition and the maximum of 3 child
dependents. This is further clarified in regulation that the premium for family coverage
is determined by summing the premiums for each individual family member, provided
at most three child dependents under age 21 are taken into account; this adjustment
does not result in a separate rating factor. Family tiering only occurs in states that use
pure community rating and are uniformly applied to all plans in the risk pool (and
published to the cciio.cms.gov website).

Worksheet 1 – Market Experience

The purpose of Worksheet 1 is to capture information at the market level for non‐
grandfathered products, consistent with the requirement to set premium rates using a single
risk pool, as defined in 45 CFR Part 156, §156.80. The worksheet is not intended to prescribe a
rate development methodology. Rather, the worksheet captures experience period data and
key assumptions consistent with those used in the development of the proposed premium rate
increases. The worksheet uses the data to show that the average gross premium rate complies
with the requirements of the single risk pool, and reports the total and annualized change in
the gross premium relative to the experience period. These calculated changes in the average
premium are not equal to the average rate increase of the pool, but rather provide information
proposed premium rate
increases. The worksheet uses the data to show that the average gross premium rate complies
with the requirements of the single risk pool, and reports the total and annualized change in
the gross premium relative to the experience period. These calculated changes in the average
premium are not equal to the average rate increase of the pool, but rather provide information

7

on how the average gross premiums have changed over time. There are four sections in this
worksheet.

• The General Information section captures information about the issuer, state and the
health insurance market to which the proposed rate increases will apply. This
information is displayed on all worksheets of the Part I Unified Rate Review Template.

• Section I captures summarized historical financial and enrollment information from a
recent historical experience period.

• Section II captures historical claims experience on a more granular level, along with the
key assumptions employed to project the experience period information forward to the
projection period of the effective date.

• Section III displays the assumptions used to adjust the projected allowed claims to
incurred claims at the average anticipated benefit level. Administrative expense loads
and risk/profit charge loads are also captured. Using this information, the average gross
premium for the single risk pool is generated.

General Information

Company Legal Name: Enter the organization’s legal entity name.

The name entered in this cell must be the name that is associated with the HIOS Issuer
ID.

State: Enter the state that has regulatory authority over the policies. A separate template must
be completed for each state in which the issuer is applying for QHP certification or proposing a
rate increase on non‐grandfathered policies in the individual, small group or combined markets.

HIOS Issuer ID: Enter the HIOS ID assigned to the legal entity.

Market: Select the applicable market from the drop‐down box
e that has regulatory authority over the policies. A separate template must
be completed for each state in which the issuer is applying for QHP certification or proposing a
rate increase on non‐grandfathered policies in the individual, small group or combined markets.

HIOS Issuer ID: Enter the HIOS ID assigned to the legal entity.

Market: Select the applicable market from the drop‐down box. Valid markets are Individual,
Small Group, or Combined.

The market chosen must be consistent with the state’s determination of their allowable
markets (e.g. if a state chooses to merge the individual and small group market, the
issuer must choose “Combined”).

Effective Date: Enter the effective date for which rates are being submitted.

If the submission is for the individual or combined markets, the effective date must be
January 1 of the year for which rates are being submitted. If the submission is for the
small group market, enter the effective date for which the Index Rate is being revised.
For example, if the small group submission revises the Index Rate for July 1, 2015

8

effective dates and includes a trend increase applicable on October 1, 2015, enter July 1,
2015. See the Appendix for further guidance on trend increases in the small group
market.

All issuers are required to file the Part I Unified Rate Review Template and Part III Actuarial
Memorandum annually for an effective date of January 1 of each year. Subject to state
requirements, small group issuers are allowed to file subsequent submissions that reset the
Index Rate for the remainder of the calendar year.  However, the change in the Index Rate is
only allowed to occur for the remainder of the calendar year and subsequent submission is
required for the beginning of the next calendar year.

For example, if a small group issuer submits the Part I Unified Rate Review Template for
January 1, they may submit a subsequent Part I Unified Rate Review Template that
resets the Index Rate effective July 1 of that same year
e in the Index Rate is
only allowed to occur for the remainder of the calendar year and subsequent submission is
required for the beginning of the next calendar year.

For example, if a small group issuer submits the Part I Unified Rate Review Template for
January 1, they may submit a subsequent Part I Unified Rate Review Template that
resets the Index Rate effective July 1 of that same year. The Part I Unified Rate Review
Template effective July 1 in this example is only allowed to contain a trend increase for
October 1 of that same year. Quarters after October 1 would be included in the next
annual submission effective January 1 of the next calendar year.

All products and plans must have the same effective date; however, some products or
plans may have a 0% rate change. The term “product” is defined as a unique
combination of benefits, various cost sharing options and a network design(s) to a
particular service area.  “Product” has the same meaning as included in 45 CFR Part 154.
The term “plan” is defined as a unique combination of benefits to a specific set of cost
sharing options and network design(s) to a particular service area.  Most products will
be made up of multiple plans produce an actuarial value equal to one of the metal levels
permitted under Title I of the Patient Protection and Affordable Care Act, as amended
by the Health Care and Education Reconciliation Act of 2010, collectively referred to as
the Affordable Care Act (ACA).

Section I

The financial and enrollment information entered in this section should reflect the experience
of all non‐grandfathered policies for the specified market and state. The information is
intended to reflect the single risk pool for the market as required by the ACA and 45 CFR
156.80. The information in this section should reflect historical financial and enrollment
information for the identified legal entity only.

Experience Period: Enter the first date of the experience period
perience
of all non‐grandfathered policies for the specified market and state. The information is
intended to reflect the single risk pool for the market as required by the ACA and 45 CFR
156.80. The information in this section should reflect historical financial and enrollment
information for the identified legal entity only.

Experience Period: Enter the first date of the experience period.

The Experience Period must be a twelve month period. The template calculates the end
date of the experience period such that the period is twelve months long.

9

For individual and combined market submissions, the Experience Period must be a
calendar year period. It should be the most recently completed calendar year; if not,
include an explanation in the Part III Actuarial Memorandum. Therefore, the first date of
the Experience Period must be January 1. For small group market submissions, the first
date of the Experience Period must be the first date of a calendar quarter, i.e., January
1, April 1, July 1, or October 1.

If an experience period other than that required to be shown is used in the derivation of
the Index Rate, then the credibility manual rate section should be used to show the
Index Rate development and described in the Part III Actuarial Memorandum.

The Experience Period reflects a period during which premiums were earned and claims
were incurred. For example, if the Experience Period is January 1, 2012 through
December 31, 2012 the issuer may include claims payments through a date beyond the
end of the experience with dates of service within the Experience Period (e.g., February
28, 2013) when estimating the total claims incurred during the period. The paid through
date is not captured in the template, but is requested in the Part III Actuarial
Memorandum
xperience Period is January 1, 2012 through
December 31, 2012 the issuer may include claims payments through a date beyond the
end of the experience with dates of service within the Experience Period (e.g., February
28, 2013) when estimating the total claims incurred during the period. The paid through
date is not captured in the template, but is requested in the Part III Actuarial
Memorandum.

Premiums (net of MLR Rebate) in Experience Period: Enter the amount of premium earned
during the experience period, net of rebates to policyholders on an incurred basis due to the
medical loss ratio (MLR) requirements as defined in 45 CFR Part 158.

Start with premiums earned during the experience period. Subtract the actual or
estimated MLR rebates incurred during the experience period.

Enter the aggregate net premium dollars earned. The template will calculate the per
member per month (PMPM) premium amount and the percent of premium.

Do not subtract amounts from the net earned premium that would be subtracted from
earned premium in the denominator of the MLR calculation, such as taxes and fees.  For
portions of the experience period for which the MLR rebate has not been finalized,
include a best estimate of the rebates in the reported net premium. See the Part III
Actuarial Memorandum instructions for required documentation of the method used to
estimate rebates.

Incurred Claims in Experience Period: Enter total claims incurred in the Experience Period.

Enter the aggregate incurred claims. The template calculates the PMPM incurred claims
amount and the incurred claims as a percent of premium. The calculated percent of
premium attributable to claims is not equivalent to the MLR, and therefore may be less
than 80%.
method used to
estimate rebates.

Incurred Claims in Experience Period: Enter total claims incurred in the Experience Period.

Enter the aggregate incurred claims. The template calculates the PMPM incurred claims
amount and the incurred claims as a percent of premium. The calculated percent of
premium attributable to claims is not equivalent to the MLR, and therefore may be less
than 80%.

10
Incurred claims are defined as allowed claims (defined immediately below) less member

cost sharing and cost sharing paid by HHS on behalf of low‐income members.

Member cost sharing is defined as payments made against the allowed claims by the
member for health care services (e.g., deductible, coinsurance and copayments). This
does not include premium or the amount of billed charges the member must pay in
excess of the issuer’s contractual allowed amount (often described as “balance billing”).

Allowed Claims: Enter total allowed claims with dates of service during the Experience Period.

Allowed Claims are defined as the total payments made under the policy to healthcare
providers on behalf of covered members, and include payments made by the issuer,
member cost sharing, and cost sharing paid by HHS on behalf of low‐income members.
Consequently, they include actual payments made or estimates of costs incurred but not
yet paid during the period.  See Part III of the Actuarial Memorandum instructions for
guidance related to incurred but not paid claim reserve documentation. They also
include claims not tied to a specific date of service, such as capitation or risk sharing
payments, if the payments were for services provided during the Experience Period.
They include claims for essential health benefits (EHB) as well as benefits other than
EHB. This would not include the amount of billed charges the member must pay in
excess of the issuer’s contractual allowed amount (often described as “balance billing”)
cific date of service, such as capitation or risk sharing
payments, if the payments were for services provided during the Experience Period.
They include claims for essential health benefits (EHB) as well as benefits other than
EHB. This would not include the amount of billed charges the member must pay in
excess of the issuer’s contractual allowed amount (often described as “balance billing”).

By definition, “Allowed Claims” do not include:

• Ineligible claims such as duplicate claims, third party liabilities (e.g. coordination
of benefits claims), and any other claims that are denied under the policy terms.

• Payments for services other than medical care provided, (e.g., medical
management, quality improvement, and fraud detection and recovery expenses)
even if these amounts are included in claims for MLR reporting purposes.

• Recovery payments the issuer may receive from private reinsurance or internal
large claim pooling mechanisms. These types of adjustments should be handled
in the Other adjustment factor found in Section II of Worksheet 1.

• Active life reserves (policy reserves, contract reserves, contingency reserves, or
any kind of reserves except traditionally defined reserves for claims incurred but
not paid) or change in such reserves.

Index Rate of Experience Period: Enter the Index Rate underlying the Experience Period. The
value entered in this field must be a whole dollar value (i.e. the rate must be rounded to the
nearest $1). Please note, if an issuer copies and pastes a value in this cell which contains
decimals, the Part I Unified Rate Review Template submission could be rejected or an issuer
nge in such reserves.

Index Rate of Experience Period: Enter the Index Rate underlying the Experience Period. The
value entered in this field must be a whole dollar value (i.e. the rate must be rounded to the
nearest $1). Please note, if an issuer copies and pastes a value in this cell which contains
decimals, the Part I Unified Rate Review Template submission could be rejected or an issuer

11
may be required to make a resubmission later in the process which could delay the rate review

process and approval.

The Index Rate represents the average allowed claims PMPM for essential health
benefits. It is the legal entity‐specific rate for the market that is being submitted – i.e.,
the issuer’s individual market, small group market or combined market. It should not be
adjusted for payments and charges under the risk adjustment and reinsurance programs
or for Exchange user fees. It is simply allowed claims PMPM for essential health
benefits.

The Index Rate should be developed using all covered members, even if premium was
not explicitly collected for all members. For example, if the number of members in a
given family or policy was capped for premium setting purposes either voluntarily by the
issuer or as required by law, all family members covered by the policy should be
included.

The experience period Index Rate should be adjusted to exclude benefits that are in
excess of essential health benefits, but should not be adjusted to include essential
health benefits that were not covered during the experience period, such as, in some
cases, maternity coverage in the individual market.

Experience Period Member Months: Enter the total number of months of coverage in the
Experience Period for all members that had coverage during any portion of the Experience
Period.

For example, if a given member had coverage for five months during the Experience
Period, that member would contribute five member months to the total member
months for the period. The number entered must be an integer
nce Period Member Months: Enter the total number of months of coverage in the
Experience Period for all members that had coverage during any portion of the Experience
Period.

For example, if a given member had coverage for five months during the Experience
Period, that member would contribute five member months to the total member
months for the period. The number entered must be an integer. For partial months,
issuers should define a methodology for counting partial months and apply the
methodology consistently to all members. Possible methodologies include but are not
limited to rounding up, rounding down, rounding to nearest, counting the member
month if the member is active on the 15th of the month, etc.

Include all covered members even if premium was not explicitly collected for all
members. For example, if the number of members in a given family or policy was
capped for premium setting purposes either voluntarily by the issuer or as required by
law.

Section II: Allowed Claims, PMPM basis

Projection Period: The projection period is determined by the template. The Projection Period
starts on the effective date entered in the General Information section of the template. The
Projection Period end date is calculated such that the Projection Period is a twelve month

12

period. The template also calculates the number of months between the midpoint of the
Experience Period and the midpoint of the Projection Period.

Benefit Category

Several fields that follow require issuers to enter data by Benefit Category. Issuers are required
to describe the Benefit Category definitions in the Part III Actuarial Memorandum. The
preferred definitions of the Benefit Category follow:

Inpatient Hospital: Includes non‐capitated facility services for medical, surgical, maternity,
mental health and substance abuse, skilled nursing, and other services provided in an inpatient
facility setting and billed by the facility
uers are required
to describe the Benefit Category definitions in the Part III Actuarial Memorandum. The
preferred definitions of the Benefit Category follow:

Inpatient Hospital: Includes non‐capitated facility services for medical, surgical, maternity,
mental health and substance abuse, skilled nursing, and other services provided in an inpatient
facility setting and billed by the facility.

Outpatient Hospital: Includes non‐capitated facility services for surgery, emergency room, lab,
radiology, therapy, observation and other services provided in an outpatient facility setting and
billed by the facility.

Professional: Includes non‐capitated primary care, specialist, therapy, the professional
component of laboratory and radiology, and other professional services, other than hospital
based professionals whose payments are included in facility fees.

Other Medical: Includes non‐capitated ambulance, home health care, DME, prosthetics,
supplies, vision exams, dental services and other services.

Capitation: Includes all services provided under one or more capitated arrangements.

Prescription Drug: Includes drugs dispensed by a pharmacy. This amount should be net of
rebates received from drug manufacturers.

Experience Period on Actual Experience Allowed

The experience entered in this section needs to reflect the state and market identified in the
General Information section and the Experience Period identified in Section I of this worksheet.
The actual experience for this period, state and market should be entered in the template,
regardless of the credibility level.

Utilization Description: For each Benefit Category, choose the appropriate measurement unit
that reflects the utilization per 1,000 covered members per year from the drop down menu.
Valid entries are shown below.

Admits (for Inpatient service category only)
Days (for Inpatient service category only)
Benefit Period (for Capitation service category only)
Visits
of the credibility level.

Utilization Description: For each Benefit Category, choose the appropriate measurement unit
that reflects the utilization per 1,000 covered members per year from the drop down menu.
Valid entries are shown below.

Admits (for Inpatient service category only)
Days (for Inpatient service category only)
Benefit Period (for Capitation service category only)
Visits

13

Services
Prescriptions (for Prescription Drug service category only)
Other

In cases where “Other” is selected provide additional descriptions of the measurement
units in the Part III Actuarial Memorandum.

Utilization per 1,000: Enter the total utilization per 1,000 covered members per year for claims
incurred during the Experience Period.

The utilization must be entered on an annualized basis. Include any necessary estimates
of utilization related to claims incurred but not yet paid.

Average Cost/Service: Enter the average allowed cost per unit of service for claims incurred
during the Experience Period.

While not required, issuers may adjust the average cost per service for claims incurred
but not yet paid if the issuer estimates the claims not yet paid to have a different
average cost per service than those already paid. If an adjustment is made it should be
described in the Part III Actuarial Memorandum.

PMPM: The Allowed Claims PMPM is calculated by the template, and is equal to utilization per
1,000 times average cost per service, divided by 12,000. The template sums the PMPM from
each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the
Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.

Adjustments from Experience to Projection Period

Population risk Morbidity: Enter the assumed change in morbidity of the covered population
from the Experience Period to the Projection Period
,000. The template sums the PMPM from
each Benefit Category to calculate the total PMPM. The calculated PMPM must equal the
Allowed Claims PMPM calculated by the template in Section I of Worksheet 1.

Adjustments from Experience to Projection Period

Population risk Morbidity: Enter the assumed change in morbidity of the covered population
from the Experience Period to the Projection Period.

“Change in morbidity” means that component of the change in average allowed claims
PMPM (as described earlier in these instructions) that will occur under the
circumstances where all demographic (e.g., age, gender, and region) and product mix,
all provider network contracts and time parameters (i.e., trends = 0) are held constant
on the population that exists in the Experience Period.

The change in morbidity must be entered as 1 plus the total anticipated percent change
in morbidity from the Experience Period to the Projection Period. For example, if in a 24
month period from the Experience Period to the Projection period the morbidity is
expected to increase by 10%, enter 1.100. Similarly, if the morbidity is expected to
decrease by 10% over the 24 month period, enter 0.900.

14

This category may include a number of adjustments since the market rules during the
Projection Period may be significantly different from those in the Experience Period. In
addition, the impact of new market rules is expected to vary significantly state to state.
Some of the adjustments issuers might include are:

• Guarantee issue
• Take‐up rate of the uninsured (the percent of currently uninsured that purchase
coverage during the projection period)
• Health status of newly insured
• Enrollment from prior high risk pools
• Induced demand of newly insured
• Pent‐up demand of newly insured
• Subsidy effects

Expected changes in the demographic mix (e.g. age, gender, and region) and tobacco
status should not be included in this factor. These factors can be included in the “Other”
factor
rchase
coverage during the projection period)
• Health status of newly insured
• Enrollment from prior high risk pools
• Induced demand of newly insured
• Pent‐up demand of newly insured
• Subsidy effects

Expected changes in the demographic mix (e.g. age, gender, and region) and tobacco
status should not be included in this factor. These factors can be included in the “Other”
factor.

A description of the methodology used to develop the adjustment must be included in
the Part III Actuarial Memorandum.

Other: Enter the assumed change in cost related to things other than a change in population
morbidity, cost trend, and utilization trend. Cost trend and utilization trend are defined in the
section immediately following.

The other change must be entered as 1 plus the total anticipated percent change in cost
from the Experience Period to the Projection Period, similar to the Population risk
Morbidity adjustment.

Some of the adjustments an issuer might include in this section are:

• Changes in covered services

• Significant changes in the provider network, such as adding or removing a
provider system, or introducing a limited network option. Shifts in the
distribution of services across existing network providers should be reflected in
the Cost Trend.

• Projected changes in cost related to demographics of the projected covered
population

• Projected changes in pharmacy rebates relative to the pre‐rebate prescription
drug allowed claims
, such as adding or removing a
provider system, or introducing a limited network option. Shifts in the
distribution of services across existing network providers should be reflected in
the Cost Trend.

• Projected changes in cost related to demographics of the projected covered
population

• Projected changes in pharmacy rebates relative to the pre‐rebate prescription
drug allowed claims

15

• In the event an issuer has capitation in the experience period but does not
expect to have capitation in the projection period, the issuer should enter a
near‐zero value in the “Other” projection factor to remove the costs. It is not
anticipated that other EHB categories would need to remove the experience for
the entire benefit category.

A description of the methodology used to develop the adjustment must be included in
the Part III Actuarial Memorandum.

Annualized Trend Factors

Cost Trend: Enter the assumed change in cost per service from the Experience Period to the
Projection Period.

The Cost Trend must be entered as 1 plus the annualized trend assumption. For
example, if the period from the midpoint of the Experience Period to the midpoint of
the Projection Period is 24 months and if costs in the projection period are expected to
be 10.25% higher than the Experience Period, then the annual trend is 5.0% (√1.1025 ‐
1). In this example, the user should enter 1.050 (√1.1025ሻ.

Include only the increase in cost for a fixed basket of services. Changes in cost related to
changes in mix of services should not be reflected here (they will be reflected in
utilization trend described below). Changes in cost related to a change in the
distribution of services across network providers should be included. Significant changes
in network, such as adding or removing a provider system, or introducing a limited
network option should be reflected in the “Other” adjustment and described in the Part
III Actuarial Memorandum
here (they will be reflected in
utilization trend described below). Changes in cost related to a change in the
distribution of services across network providers should be included. Significant changes
in network, such as adding or removing a provider system, or introducing a limited
network option should be reflected in the “Other” adjustment and described in the Part
III Actuarial Memorandum.

Projected changes in prescription drug cost related to manufacturer rebates should be
reflected in the “Other” adjustment.

Utilization Trend: Enter the assumed change in utilization per 1,000 members from the
Experience Period to the Projection Period.

The Utilization Trend must be entered as 1 plus the annualized trend assumption, in the
same manner as the cost trend.

Utilization Trend should include the change in the number of units per 1,000 members
for a fixed level of illness burden. If utilization is expected to increase/decrease due to a
change in the average health status of the population, that change should be reflected
in the Population risk Morbidity adjustment described above.

Utilization Trend should include assumed changes in the mix or intensity of services
provided for a fixed level of illness burden.

16

Utilization Trend should also reflect changes related to shifts in product mix. This
includes changes in induced demand related to product shifts. It also includes any
effects of selection since this cannot be reflected in the relative cost of the various
products and plans offered.

Projections, before credibility Adjustment

Projections before credibility adjustment are calculated by the template.

Utilization per 1,000: The template calculates projected utilization per 1,000 by multiplying the
experience period utilization per 1,000 by the Population risk Morbidity adjustment and the
utilization trend assumption
tive cost of the various
products and plans offered.

Projections, before credibility Adjustment

Projections before credibility adjustment are calculated by the template.

Utilization per 1,000: The template calculates projected utilization per 1,000 by multiplying the
experience period utilization per 1,000 by the Population risk Morbidity adjustment and the
utilization trend assumption. The Utilization Trend assumption in this calculation is raised to the
power of the number of months between the midpoint of the Experience Period and the
midpoint of the Projection Period (calculated previously by the template), divided by 12.

Average Cost/Service: The template calculates the projected average cost per service by
multiplying the experience period average cost per service by the Other adjustment and the
cost trend assumption. The Cost Trend assumption in this calculation is raised to the power of
the number of months between the midpoint of the Experience Period and the midpoint of the
Projection Period (calculated previously by the template), divided by 12.

PMPM: The projected allowed claims PMPM is calculated by the template, and is equal to
projected Utilization per 1,000 times projected Average Cost/Service, divided by 12,000. The
template sums the PMPM from each Benefit Category to calculate the total PMPM.

Credibility Manual

The credibility manual Utilization per 1,000 and Average Cost /Service need only be populated
with values greater than zero if the experience period claims data is less than 100% credible for
projecting future premium rates. When the experience period claims data is 100% credible
zeros must still be entered in the credibility manual section so as not to produce errors when
the template is validated. While credibility may not be applied in this manner in rate
development, it must be shown in this manner for reporting purposes.

Utilization per 1,000: Enter the assumed utilization per 1,000 for the data underlying the
credibility manual
iod claims data is 100% credible
zeros must still be entered in the credibility manual section so as not to produce errors when
the template is validated. While credibility may not be applied in this manner in rate
development, it must be shown in this manner for reporting purposes.

Utilization per 1,000: Enter the assumed utilization per 1,000 for the data underlying the
credibility manual.

The Utilization per 1,000 must reflect the population and covered services for which
rates are being submitted. If the issuer uses another credible block of business as the
credibility manual, for example, the utilization of that population should be adjusted to
reflect morbidity consistent with the projected population. Other adjustments may be
necessary. The source of the credibility manual Utilization per 1,000 and the
adjustments applied to it should be described in the Part III Actuarial Memorandum.

17

Average Cost/Service: Enter the assumed average cost per service for the data underlying the
credibility manual.

The cost per service must reflect the projected cost for the population and covered
services for which rates are being submitted. If the issuer uses another credible block of
business from a different geographic region as the credibility manual, for example, the
cost for that population should be adjusted to reflect differences in provider contracting
of the two regions. The source of the credibility manual average cost per service and the
adjustments applied to it should be described in the Part III Actuarial Memorandum.

PMPM: The projected credibility manual PMPM is calculated by the template, and is equal to
the credibility manual Utilization per 1,000 times the credibility manual Average Cost/Service,
divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the
total PMPM
t per service and the
adjustments applied to it should be described in the Part III Actuarial Memorandum.

PMPM: The projected credibility manual PMPM is calculated by the template, and is equal to
the credibility manual Utilization per 1,000 times the credibility manual Average Cost/Service,
divided by 12,000. The template sums the PMPM from each Benefit Category to calculate the
total PMPM.

Section III: Projected Experience

Projected Amounts After Credibility

Credibility Percentage: Enter the assumed level of credibility to be applied to the experience
period claims that have been projected to the rating period.

The percentage must be between 0% and 100%. Describe the methodology used to
determine the Credibility Percentage in the Part III Actuarial Memorandum.

The template calculates the credibility to be assigned to the credibility manual, and is
equal to 1 minus the credibility assigned to the projected experience claims.

Projected Allowed Experience Claims PMPM (w/ applied credibility if applicable): The
template calculates this value as the sum of the projected experience PMPM multiplied by its
credibility, and the credibility manual PMPM multiplied by the complement of the credibility
(calculated previously by the template).

Paid to Allowed Average Factor in the Projection Period: Enter the average paid to allowed
factor for the Projection Period.

This amount is not from the AV calculator. It should equal the total expected paid claims
that are the liability of the issuer divided by the total expected allowed claims for the
Projection Period, for the population anticipated to be covered in the Projection Period.
Allowed claims have the same definition as in Section I. Paid claims are analogous to the
Incurred Claims defined in Section I. Paid claims are net of member cost sharing and cost
sharing paid by HHS on behalf of low‐income members
ability of the issuer divided by the total expected allowed claims for the
Projection Period, for the population anticipated to be covered in the Projection Period.
Allowed claims have the same definition as in Section I. Paid claims are analogous to the
Incurred Claims defined in Section I. Paid claims are net of member cost sharing and cost
sharing paid by HHS on behalf of low‐income members. The Paid to Allowed Average
Factor in the Projection Period should reflect the average benefit level anticipated
during the projection period. For example, if the issuer’s members were enrolled

18

primarily in Silver plans in the experience period, but are anticipated to shift to Bronze,
then the Paid to Allowed Average Factor in the Projection Period should reflect Bronze
cost sharing levels.

Since the paid claims in the numerator are the trended amounts for the Projection
Period, they should reflect any leveraging of fixed dollar cost sharing inherent in the
benefit plans. That is, if no change in benefit mix is anticipated relative to the
Experience Period, the paid to allowed ratio should be higher in the projection period
than what was realized in the experience period due to the leveraging of cost sharing.

Projected Incurred Claims, before ACA rein & Risk Adj’t, PMPM: The template calculates this
value by multiplying the Projected Allowed Experience Claims PMPM (w/ applied credibility if
applicable) by the Paid to Allowed Average Factor in the Projection Period.

Projected Risk Adjustments, PMPM: Enter the projected PMPM amount of net federal risk
adjustment transfers (i.e., net effect of risk adjustment payments and charges) for the
Projection Period, and net of risk adjustment user fees.

The risk transfers should reflect the projected morbidity, including any projected
Population risk Morbidity changes in column J in Section II.

If the issuer expects to receive a projected risk adjustment charge, then the entry should
be a positive value
nt transfers (i.e., net effect of risk adjustment payments and charges) for the
Projection Period, and net of risk adjustment user fees.

The risk transfers should reflect the projected morbidity, including any projected
Population risk Morbidity changes in column J in Section II.

If the issuer expects to receive a projected risk adjustment charge, then the entry should
be a positive value. If the issuer expects to make a projected risk adjustment payment,
then the entry should be a negative value.
Risk adjustment user fees should be reflected here, and not in the Taxes & Fees.
The calculation of the projected risk adjustments should consider the appropriate
published transfer equation. Please describe the methodology for estimating the PMPM
amount in the Part III Actuarial Memorandum.

Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM: The
template calculates this value by subtracting the Projected Risk Adjustments, PMPM from the
Projected Incurred Claims, before ACA rein & Risk Adj’t, PMPM.

Projected ACA Reinsurance Recoveries, Net of Premium: Enter projected reinsurance
recoveries, referred to as reinsurance payments in the HHS Notice of Benefit and Payment
Parameters, from the Federal reinsurance program, less contributions made to the program
(referred to as “Premium” in the template).

Recoveries should be entered as positive amounts. For example, in the individual market
where recoveries will likely exceed assessments the amount should be positive. In
combined markets, the value may be positive or negative depending upon the portion of
the market that is expected to be comprised of individuals and small groups. In a
he program
(referred to as “Premium” in the template).

Recoveries should be entered as positive amounts. For example, in the individual market
where recoveries will likely exceed assessments the amount should be positive. In
combined markets, the value may be positive or negative depending upon the portion of
the market that is expected to be comprised of individuals and small groups. In a

19

combined market, the pooled reinsurance adjustment should be based only on the
portion of the issuer’s individual market business eligible for reinsurance payments. For
the small group market, this amount only reflects the reinsurance assessment and
should be entered as a negative number.

Projected Incurred Claims: The template calculates this value by subtracting Projected Risk
Adjustments, PMPM and Projected ACA Reinsurance Recoveries, Net of Premium from
Projected Incurred Claims, before ACA rein & Risk Adj’t, PMPM.

Administrative Expense Load: Enter the administrative expense load included in the premiums
being filed for the effective date.

Enter the load as a percentage of premium. The template uses the percentage to
calculate the PMPM administrative expense load.

If the Administrative Expense Load varies by product or plan, enter the average expense
load for the single risk pool, using a premium‐weighted average.

The Administrative Expense Load should include expense loads related to quality
improvement and fraud detection/recovery, even if those expenses are considered part
of incurred claims for purposes of MLR rebate calculations. It should also include loads
for taxes and fees that may not be subtracted from premium in the MLR rebate
calculation. For reporting purposes, it should not include the profit and risk load or the
taxes and profit load, both described below, even though they are considered
administrative expenses for purposes of adjusting the Index Rate to arrive at premium in
the pricing process
alculations. It should also include loads
for taxes and fees that may not be subtracted from premium in the MLR rebate
calculation. For reporting purposes, it should not include the profit and risk load or the
taxes and profit load, both described below, even though they are considered
administrative expenses for purposes of adjusting the Index Rate to arrive at premium in
the pricing process.

Profit & Risk Load: Enter the profit and risk load included in the premiums being filed for the
effective date.

Enter the load as a percentage of premium. Not‐for‐profit issuers should enter the load
for contribution to surplus in this entry. The template uses the percentage to calculate
the PMPM profit and risk load.

If the Profit & Risk Load varies by product or plan, enter the average profit and risk load
for the single risk pool, using a premium‐weighted average.

Since taxes (including any federal income tax) are captured separately in the Taxes &
Fees input, the profit and risk load should reflect after‐tax amounts.

Note that for pricing purposes, profit and risk load is considered part of administrative
expenses, per 45 CFR Part 156, §156.80(d). It is shown separately on the template to
facilitate rate review.

20

Taxes & Fees: Enter the taxes and fees included in the premiums being filed for the effective
date.

Enter only the portion of any load that is for taxes and fees that may be subtracted from
premiums for purposes of calculating MLR. This includes federal income tax.  However,
do not include any contributions to the Federal transitional reinsurance program or risk
adjustment user fees in this amount despite their treatment in MLR calculations, since
Federal reinsurance and risk adjustment amounts are expressed in the template net of
reinsurance premium and risk adjustment user fees. Any additional load for taxes and
fees should be reflected in the Administrative Expense Load. The template uses the
percentage to calculate the PMPM Taxes & Fees
m or risk
adjustment user fees in this amount despite their treatment in MLR calculations, since
Federal reinsurance and risk adjustment amounts are expressed in the template net of
reinsurance premium and risk adjustment user fees. Any additional load for taxes and
fees should be reflected in the Administrative Expense Load. The template uses the
percentage to calculate the PMPM Taxes & Fees.

If the Taxes & Fees percentage varies by product or plan, enter the average Taxes &
Fees percentage for the single risk pool, using a premium‐weighted average.

Note that for pricing purposes, taxes and fees are considered part of administrative
expenses, per 45 CFR Part 156, §156.80(d). It is shown separately on the template to
facilitate rate review.

Single Risk Pool Gross Premium Avg. Rate, PMPM: The template calculates this value by
dividing the Projected Incurred Claims by 1 minus the Administrative Expense Load percentage
less the Profit & Risk Load percentage less Taxes & Fees percentage.

Index Rate for Projection Period: Enter the projected Index Rate.

As noted in Section I, the Index Rate represents the average allowed claims PMPM for
essential health benefits. This legal entity‐specific rate for the projection period should
not reflect any adjustments for payments and charges under the risk adjustment and
reinsurance programs or for Exchange user fees. It is simply projected allowed claims
PMPM for essential health benefits. If the submission is for the individual or combined
market, the projected Index Rate should reflect the twelve month projection period, or
rating period. For the individual or combined market, if the issuer will not be covering
benefits in excess of EHB, the Index Rate for the projection period will be equal to the
Projected Allowed Experience Claims PMPM (w/ applied credibility if applicable)
If the submission is for the individual or combined
market, the projected Index Rate should reflect the twelve month projection period, or
rating period. For the individual or combined market, if the issuer will not be covering
benefits in excess of EHB, the Index Rate for the projection period will be equal to the
Projected Allowed Experience Claims PMPM (w/ applied credibility if applicable). If the
submission is for the small group market and includes prospective trend adjustments
(only if permitted by the state), then the Index Rate for Projection Period should reflect
the member weighted average of the projected trended Index Rates applicable for each
effective date in the submission. See Section I for additional information about the
Index Rate. See the Appendix for further guidance on calculation of the small group
weighted average projected Index Rate.

% increase over Experience Period: The template calculates this value which represents the
percent increase in the projected average gross premium PMPM over the average gross
premium PMPM in the experience period. The average gross premium PMPM for the

21

experience period is calculated by the template in Section I (Premiums (net of MLR Rebate) in
Experience Period).

The calculated increase is not the proposed rate increase. The calculated increase may
include changes in premium PMPM related to shifts in the covered benefit, age,
geographic area, or tobacco status of the population, some of which may be charged to
the consumer through allowable rating factors.

The period of time over which the increase is calculated is dependent upon the
Experience Period entered by the issuer. For example, if the length of time between the
Experience Period and the Projection Period is two years, the increase calculated will
represent a two‐year increase.

% increase, annualized: The template calculates this value by annualizing the % increase over
Experience Period
period of time over which the increase is calculated is dependent upon the
Experience Period entered by the issuer. For example, if the length of time between the
Experience Period and the Projection Period is two years, the increase calculated will
represent a two‐year increase.

% increase, annualized: The template calculates this value by annualizing the % increase over
Experience Period. Like the % increase over Experience Period, the calculated increase may
include changes in premium PMPM related to shifts in the covered benefits, age, geographic
area, or tobacco status of the population, some of which may be charged to the consumer
through allowable rating factors.

Projected Member Months: Enter the number of member months expected to be covered
during the Projection Period.

See ‘Experience Period Member Months’ in Section I for more information on how to
calculate member months. Since the Projection Period must be a one‐year period, the
projected member months might be equal to 12 times the projected enrollment in the
first month of the Projection Period, for example. Issuers should describe how the
member months were projected in the Part III Actuarial Memorandum.

Include all covered members even if premium is not expected to be explicitly collected
for all members, for example if the number of child members in a given family exceeds
three and must be

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- [PR Carta Circular Núm. 10-164-57 Informe de negocios de agentes generales](https://www.frixlaw.com/law-library/statutes/PR_INS_B_CC-10-164-57.md)
- [PR Carta Circular Núm. 10-165-57 Horario de la Superintendencia de Seguros](https://www.frixlaw.com/law-library/statutes/PR_INS_B_CC-10-165-57.md)
- [PR Carta Circular Núm. 10-168-57 Directorio de Compañías](https://www.frixlaw.com/law-library/statutes/PR_INS_B_CC-10-168-57.md)
- [PR Carta Circular Núm. 10-169-57 Informe de negocios de los agentes generales](https://www.frixlaw.com/law-library/statutes/PR_INS_B_CC-10-169-57.md)
- [PR Carta Circular Núm. 11-137-56 Tarifas para riesgos de incendio, robo, huracán y la cubierta comprensiva](https://www.frixlaw.com/law-library/statutes/PR_INS_B_CC-11-137-56.md)
- [PR Carta Circular Núm. 11-139-56 Tarifas para seguros de automóviles de empleados](https://www.frixlaw.com/law-library/statutes/PR_INS_B_CC-11-139-56.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/PR_INS_B_CN-2014-175-AS. Check the current official text before relying on it. Not legal advice.