Washington Revised Code Title 48. Insurance § 48.44.017. Schedule of rates for individual contracts--Loss ratio--Definitions

(a) “Claims” means the cost to the health care service contractor of health care services, as defined in RCW 48.43.005, provided to a contract holder or paid to or on behalf of a contract holder in accordance with the terms of a health benefit plan, as defined in RCW 48.43.005.  This includes capitation payments or other similar payments made to providers for the purpose of paying for health care services for an enrollee.

(b) “Claims reserves” means:  (i) The liability for claims which have been reported but not paid;  (ii) the liability for claims which have not been reported but which may reasonably be expected;  (iii) active life reserves;  and (iv) additional claims reserves whether for a specific liability purpose or not.

(c) “Declination rate” for a health care service contractor means the percentage of the total number of applicants for individual health benefit plans received by that health care service contractor in the aggregate in the applicable year which are not accepted for enrollment by that health care service contractor based on the results of the standard health questionnaire administered pursuant to *RCW 48.43.018(2)(a).

(d) “Earned premiums” means premiums, as defined in RCW 48.43.005, plus any rate credits or recoupments less any refunds, for the applicable period, whether received before, during, or after the applicable period.

(e) “Incurred claims expense” means claims paid during the applicable period plus any increase, or less any decrease, in the claims reserves.

(f) “Loss ratio” means incurred claims expense as a percentage of earned premiums.

(g) “Reserves” means:  (i) Active life reserves;  and (ii) additional reserves whether for a specific liability purpose or not.

(a) A description of the health care service contractor's rate-making methodology;

(b) An actuarially determined estimate of incurred claims which includes the experience data, assumptions, and justifications of the health care service contractor's projection;

(c) The percentage of premium attributable in aggregate for nonclaims expenses used to determine the adjusted community rates charged;  and

(d) A certification by a member of the American academy of actuaries, or other person approved by the commissioner, that the adjusted community rate charged can be reasonably expected to result in a loss ratio that meets or exceeds the loss ratio standard of seventy-four percent, minus the premium tax rate applicable to the carrier's individual health benefit plans under RCW 48.14.0201.