Administrative Code

Creating a Report: Check the sections you'd like to appear in the report, then use the "Create Report" button at the bottom of the page to generate your report. Once the report is generated you'll then have the option to download it as a pdf, print or email the report.

Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 130. Rules Governing the Filing of Rates for Individual and Group Accident and Sickness Insurance
8/11/2020

14VAC5-130-81. Risk Pools and Index Rate.

A. This section shall only apply to individual or small employer group health insurance coverage, except for grandfathered plans and student health insurance coverage.

B. An insurer shall consider the claims experience of all individual health insurance coverage members, other than those in grandfathered plans and student health insurance coverage, to be members of a single risk pool.

C. An insurer shall consider the claims experience of all small employer group health insurance coverage members, other than those in grandfathered plans, to be members of a single risk pool.

D. Each plan year or policy year, as applicable, an insurer shall establish an index rate based on the total combined claims costs for providing essential health benefits within the single risk pool. The index rate may be adjusted on a market-wide basis based on the total expected market-wide payments and charges under the risk adjustment and reinsurance programs in this Commonwealth and the health benefit exchange user fees. The premium rate for all of the insurer's plans shall use the applicable index rate, as adjusted in accordance with subsection E of this section.

E. An insurer may vary premium rates for a particular plan from its index rate for a relevant state market based only on the following actuarially justified plan-specific factors in accordance with 45 CFR 156.80(d)(2):

1. Actuarial value and cost-sharing design of the plan.

2. The plan's provider network, delivery system characteristics, and utilization management practices.

3. Benefits provided under the plan that are in addition to the essential health benefits.

4. Administrative costs, excluding health benefit exchange user fees.

5. Only catastrophic plans may be adjusted for the expected impact of the specific eligibility categories for those plans.

Statutory Authority

§§ 12.1-13 and 38.2-223 of the Code of Virginia.

Historical Notes

Derived from Volume 29, Issue 20, eff. July 1, 2013; amended, Virginia Register Volume 32, Issue 09, eff. January 1, 2016; Volume 36, Issue 05, eff. January 1, 2020.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.