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CA Department of Insurance

California Plain-Language Filing Description

A PDF of this form is available.  Insurance companies should submit the PDF version with their rate filings.

California Plain-Language Rate Filing Description
[for Web site posting, Health & Safety  Code 1385.07(d), Insurance Code 10181.7(d)]

Text of Form:

Company Name:

SERFF Tracking Number:

Department File Number:

  1. Justification for any unreasonable rate increases
  2. Overall annual medical trend factor assumptions for all benefits:
  3. Actual Costs by Aggregate Benefit Category
Category Dollar Cost Cost as a
Percentage of Medicare

Hospital Inpatient

   
Hospital Outpatient (Including ER)    
Physician/other professional services    
Prescription Drug   Cost as a percentage of Average Wholesale Price
Laboratory (other than inpatient)    
Radiology (other than inpatient)    
Other (describe)    


  

  1. Amount of Projected Trend, by Aggregate Benefit Category, Attributable to Use of Services, Price Inflation, Fees and Risk.
Category Trend attributable to use of services Trend attributable to price inflation Trend attributable to fees and risk
Hospital Inpatient      
Hospital outpatient (including ER)      
Physician/other professional services      
Prescription Drug      
Laboratory (other than inpatient)      
Radiology (other than inpatient)      
Other      

 

  1. Other Information  Complete and submit the CA Plain Language Spreadsheet.
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