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:
- 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.
