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California New Product Rate Filing Form v2

A PDF of this form is available.  Insurance companies should use the PDF version when submitting rate initial rate filings for new products.

California New Product Rate Filing Form
For Initial Filing of Individual and Small Group Health Insurance New Product Rates, Version 2
(do not use this form for filings of rates for existing products)

The rate filing submission for new product rates should include:

  1. This form
  2. A spreadsheet with rate information responsive to Questions 10 & 15, below.

Text of form:

  1. Company Name:
  2. Number of policy forms covered by the filing.
  3. Policy form numbers covered by the filing:List all of the policy form numbers covered by this filing, and all product names associated with each policy form number, in the spreadsheet submitted in response to Question 7.
  4. Product types covered by the filing. Selected from the following: HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), EPO (Exclusive Provider Organization), POS (Point of Service), FFS (Fee for Service), Other (describe)
  5. Segment type. One of the following: Small Group (2-50 employees), Individual.Note: Large Group, Small Group, and Individual filings should not be combined within a single filing.
  6. Plan/Insurer Type. One of the following: for-profit company, not-for-profit company.
  7. Annual Rate. In a separate spreadsheet, for each product included in the filing, show the policy form number(s), each product name associated with each form number, the period for which the rates are to be effective, and the proposed annual premium rates for each rating cell.
  8. Review category: One of the following: : Initial Filing for New Product, Filing for Existing Product, Resubmission. Resubmissions should be submitted through SERFF under the same state filing number and SERFF tracking number assigned to the original submission of this filing.  Do not submit resubmissions as a new filing.
  9. Comments. Place any needed comments here.

End of text of form.

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