33-22-2204. Excess revenue -- rebate.
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/mt/title-33/chapter-22/part-22/33-22-2204·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
33-22-2204 . Excess revenue -- rebate.
(1)The commissioner shall aggregate dental loss ratios for each dental insurer by year pursuant to 33-22-2203 for each market segment in which the dental insurer operates. The commissioner shall calculate an average dental loss ratio for each market segment using aggregate data for a 3-year period, including data for the most recent dental loss ratio reporting year and the data for the two prior dental loss ratio reporting years. Newer experience is subject to reporting standards specified in 45 CFR 158.121.
(a)The commissioner shall calculate an average dental loss ratio for each market segment using the data pursuant to subsection (1), identify as outliers dental plans that fall outside 1 standard deviation of the average dental loss ratio, and report those plans to the legislature as provided in 33-22-2203 (4).
(b)A dental insurer may not be considered an outlier if its dental loss ratio in a market segment is within 3 percentage points of the average dental loss ratio. A higher threshold may be set in unique circumstances as determined reasonable by the commissioner.
(3)The commissioner shall investigate dental insurers that report a dental loss ratio lower than 1 standard deviation from the mathematical average and may take remediation or enforcement actions against them, including ordering them to rebate, in a manner consistent with 45 CFR, part 158, subpart B, all premiums paid above the amounts that would have caused the dental insurer to have achieved the mathematical average of the data submitted in a given year for a given market segment.
(4)The report in subsection
(2)is organized to show year-over-year changes in a dental insurer's outlier status relative to meeting the 1 standard deviation outlier standard in subsection (2). If the dental loss ratio for a dental insurer in a market segment does not increase and remains an outlier as described in subsection
(2)after 2 consecutive years, barring unique circumstances as determined reasonable by the commissioner, the dental insurer is subject to a minimum dental loss ratio percentage by market segment. The commissioner shall promulgate rules establishing the dental loss ratio percentage based on, at minimum, the average of existing dental insurer loss ratios by market segment in the state to be effective no sooner than 42 months after a dental insurer is determined to be an outlier.
(5)A dental insurer subject to remediation in subsections
(3)and
(4)shall provide any rebate owing to a policyholder no later than August 1 of the fiscal year following the year for which the ratio described in subsection
(1)was calculated. The commissioner may establish alternatives to direct rebates to include premium reductions in the following benefit year.
(6)The commissioner may promulgate rules that create a process to identify dental insurers that increase rates in excess of the percentage increase of the latest dental services consumer price index as reported through the bureau of labor statistics of the United States department of labor.