Form 13599 - Rating In State-Qualified Private Plans Page 2
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4OMB Clearance No. 1545-1888
2D.
Is the product(s) being offered to HCTC also available to non-HCTC individuals in the market?
(Check One)
YES
NO
If YES, please answer the following questions.
a.
Are the HCTC-eligible individuals rated on the same basis as other individuals–e.g., are they in the same
“pool” for rating purposes? (Check One)
YES
NO
b.
If the HCTC plans are rated separately from the rest of the individual market (e.g., they are rated with
some sub-groups of the individual market), please describe what the pool is/what other groups are in the
HCTC pool (e.g., HIPAA eligibles)?
c.
Are there other separate pools for certain groups in the individual market? (Check One)
YES
NO
If so, what are they (please give examples)?
2E.
What is your rate structure? (Check One)
Single
Single + Spouse
Single + Family
Other (Please Specify)
If it is a GROUP Plan complete questions 3A through 3F.
3
3A.
Is it subject to small or large group regulations in the state? (Check One)
YES
NO
3B.
Can people remain covered under the group health plan after they are no longer eligible for the HCTC?
(Check One)
YES
NO
3C.
If people lose eligibility for the group plan (once they are no longer HCTC eligible), are they eligible for:
a. Cobra? (Check One)
YES
NO
b. Another form of state continuation coverage? (Check One)
YES
NO
If so, for how long?
c.
A conversion policy? (Check One)
YES
NO
3D.
Who is the ‘administrator’ for the group plan? (i.e., what institution-insurance company, bank, state agency,
etc?) Administrator Name:
13599
Form
(7-2004)
Cat. No. 38301E
Page 2
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