§ 58-50-190. Risk Pool rates and policy forms.
§ 58‑50‑190. RiskPool rates and policy forms.
(a) The Pool shalladopt and modify, as appropriate, rates, rate schedules, rate adjustments,expense allowances, agent referral fees, claim reserve formulas, and any otheractuarial function appropriate to the operation of the Pool. Rates and rateschedules may be adjusted for appropriate factors such as age, sex, andgeographic variation in claim cost and shall take into considerationappropriate rating factors in accordance with established actuarial and underwritingpractices.
(b) The Pool shalldetermine the standard risk rate by considering the premium rates charged byother insurers offering health insurance coverage to individuals. The standardrisk rate shall be established using reasonable actuarial techniques and shallreflect anticipated experience and expenses for the coverage. Pool rates shallbe one hundred fifty percent (150%) to two hundred percent (200%) of ratesestablished as applicable for individual standard rates and shall be adjustedannually, at the time of annual renewal.
(c) The ExecutiveDirector, with the approval of the Board and the Commissioner, may developincentive programs with premium discounts. The Pool may provide for premiumsurcharges for covered individuals who are smokers. Premium surcharge ratesshall be established by the Executive Director, in collaboration with theBoard, subject to the approval of the Commissioner.
(d) Providerreimbursement rates under Pool coverage shall be limited to the rates allowedfor providers under the Medicare Program for those services covered byMedicare. The Board shall establish reimbursement rates for services for whichMedicare has not established an allowed rate. Providers rendering medical careto an insured shall accept payment of the amount established under thissubsection, including any applicable deductible, coinsurance, or co‑paymentamounts, as payment in full for services rendered.
(e) The Pool shallsubmit all premium rates and premium rate schedules and amendments to the Commissionerfor approval. The Pool shall not use any premium rates, premium rate schedules,or amendments to the rates and schedules unless the Commissioner has approvedthem. The Commissioner, in evaluating the premium rates and premium rateschedules, shall consider the factors provided in this section. The Pool shallprovide all individuals enrolled in the Pool with at least 45 days' notice ofany change in Pool premium rates or premium rate schedules.
(f) The Pool shallsubmit all policy forms, riders, endorsements, and applications for coverage tothe Commissioner for approval. The Pool shall not use any policy forms, riders,endorsements, or applications for coverages unless the Commissioner hasapproved them. Except for any provisions that are specifically treatedotherwise under this Part, the provisions of this Chapter that apply to benefitplans and policy forms of health insurers generally shall apply to the benefitplans offered and policy forms used by the Pool. (2007‑532, s. 1.1.)