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:
- Justification for any unreasonable rate increases
- Overall annual medical trend factor assumptions for all benefits:
- 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) |
|
|
- 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 |
|
|
|
- Other Information Complete and submit the CA Plain Language Spreadsheet.
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