Form 13599 - Rating In State-Qualified Private Plans Page 3

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OMB Clearance No. 1545-1888
a.
How are group member premiums determined? (Check One)
3E.
As a group (i.e. all enrollees pay the same, average rate)
As individuals
If group member premiums are determined on an Individual basis, how are they rated? (Check all that
apply)
Age
Sex
Geography
Health Status
Other (Please Specify)
b.
Is there a maximum rate or premium adjustment that can be charged to individual enrollees within the
group? (Check One)
YES
NO
N/A
YES
If YES, is this maximum based on state rating restrictions? (Check One)
NO
c. What is the maximum premium adjustment that can be applied for:
Age
Gender
Health status/claims experience/risk status
Other factors (Please Describe)
d. Are these factors otherwise used to rate individuals in group plans in the state?
YES
NO
N/A
(Check One)
e. What is your rate structure? (Check One)
Single
Single + Spouse
Single + Family
3F.
Other (Please Specify)
4.
If it is a ANOTHER POOLING ARRANGEMENT complete questions 4A through 4H:
4A.
Is the arrangement subject to individual market rules, group market rules, or some other set of state rules?
(Check One)
YES
NO
If YES, please specify
4B.
Are premium rates based on individual health/risk status? (Check One)
YES
NO
13599
Form
(7-2004)
Cat. No. 38301E
Page 3

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