Form 13599 - Rating In State-Qualified Private Plans Page 4
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4OMB Clearance No. 1545-1888
4C.
How is the underwriting structure determined? (Check One)
Set by the State (e.g. Standardized)
Based on a method established by the insurer
Other (Please Specify)
4D.
If group member premiums are determined on an Individual bases, how are they rated? (Check all that apply)
Age
Sex
Geography
Health Status
Other (Please Specify)
4E.
Is there some other factor or basis for determining premium rates in this pooling arrangement? (Check One)
YES
NO
If YES, please specify
Is there a maximum on rates that can be charged within the plan? (Check One)
YES
NO
4F.
If YES, how is the maximum determined?
Is the product(s) being offered to HCTC also available to non-HCTC individuals in the market?
4G.
(Check One)
YES
NO
d. If YES, 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
e. 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)?
f.
Are there other separate pools for certain groups in the individual market? (Check One)
YES
NO
If YES, what are they? (please give examples)
What is your rate structure? (Check One)
Single
4H.
Single + Spouse
Single + Family
Other (Please describe)
13599
Form
(7-2004)
Cat. No. 38301E
Page 4
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