CA Health & Safety Code Section 1385.045

(a)

For large group health care service plan contracts, each health plan shall file with the department the weighted average rate increase for all large group benefit designs during the 12-month period ending January 1 of the following calendar year. The average shall be weighted by the number of enrollees in each large group benefit design in the plan’s large group market and adjusted to the most commonly sold large group benefit design by enrollment during the 12-month period. For the purposes of this section, the large group benefit design includes, but is not limited to, benefits such as basic health care services and prescription drugs. The large group benefit design shall not include cost sharing, including, but not limited to, deductibles, copays, and coinsurance.

(b)

(1)A plan shall also submit any other information required pursuant to any regulation adopted by the department to comply with this article.

(2)

The department shall conduct an annual public meeting regarding large group rates within three months of posting the aggregate information described in this section in order to permit a public discussion of the reasons for the changes in the rates, benefits, and cost sharing in the large group market. The meeting shall be held in either the Los Angeles area or the San Francisco Bay area.

(c)

A health care service plan subject to subdivision (a) shall also disclose the following for the aggregate rate information for the large group market submitted under this section:

(1)

For rates effective during the 12-month period ending January 1 of the following year, number and percentage of rate changes reviewed by the following:

(A)

Plan year.

(B)

Segment type, including whether the rate is community rated, in whole or in part.

(C)

Product type.

(D)

Number of enrollees.

(E)

The number of products sold that have materially different benefits, cost sharing, or other elements of benefit design.

(2)

For rates effective during the 12-month period ending January 1 of the following year, any factors affecting the base rate, and the actuarial basis for those factors, including all of the following:

(A)

Geographic region.

(B)

Age, including age rating factors.

(C)

Occupation.

(D)

Industry.

(E)

Health status factors, including, but not limited to, experience and utilization.

(F)

Employee, and employee and dependents, including a description of the family composition used.

(G)

Enrollees’ share of premiums.

(H)

Enrollees’ cost sharing.

(I)

Covered benefits in addition to basic health care services, as defined in Section 1345, and other benefits mandated under this article.

(J)

Which market segment, if any, is fully experience rated and which market segment, if any, is in part experience rated and in part community rated.

(K)

Any other factor that affects the rate that is not otherwise specified.

(3)

(A) The plan’s overall annual medical trend factor assumptions for all benefits and by aggregate benefit category, including hospital inpatient, hospital outpatient, physician services, prescription drugs and other ancillary services, laboratory, and radiology for the applicable 12-month period ending January 1 of the following year. A health plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for professional medical services for the enrollees of the plan shall instead disclose the amount of its actual trend experience for the prior contract year by aggregate benefit category, using benefit categories, to the maximum extent possible, that are the same as, or similar to, those used by other plans.

(B)

The amount of the projected trend separately attributable to the use of services, price inflation, and fees and risk for annual plan contract trends by aggregate benefit category, including hospital inpatient, hospital outpatient, physician services, prescription drugs and other ancillary services, laboratory, and radiology. A health plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for professional medical services for the enrollees of the plan shall instead disclose the amount of its actual trend experience for the prior contract year by aggregate benefit category, using benefit categories that are, to the maximum extent possible, the same or similar to those used by other plans.

(C)

A comparison of the aggregate per enrollee per month costs and rate of changes over the last five years for each of the following:

(i)

Premiums.

(ii)

Claims costs, if any. (iii)Administrative expenses.

(iv)

Taxes and fees.

(D)

Any changes in enrollee cost sharing over the prior year associated with the submitted rate information, including both of the following:

(i)

Actual copays, coinsurance, deductibles, annual out of pocket maximums, and any other cost sharing by the benefit categories determined by the department.

(ii)

Any aggregate changes in enrollee cost sharing over the prior years as measured by the weighted average actuarial value, weighted by the number of enrollees.

(E)

Any changes in enrollee benefits over the prior year, including a description of benefits added or eliminated, as well as any aggregate changes, as measured as a percentage of the aggregate claims costs, listed by the categories determined by the department.

(F)

Any cost containment and quality improvement efforts since the plan’s prior year’s information pursuant to this section for the same category of health benefit plan. To the extent possible, the plan shall describe any significant new health care cost containment and quality improvement efforts and provide an estimate of potential savings together with an estimated cost or savings for the projection period.

(G)

The number of products covered by the information that incurred the excise tax paid by the health plan.

(d)

The information required pursuant to this section shall be submitted to the department on or before October 1, 2016, and on or before October 1 annually thereafter. Information submitted pursuant to this section is subject to Section 1385.07.