Submit Financial Filings and Reports

The DMHC provides online access to all licensed health plan's financial statements, summary information that will allow the public to quickly view vital information on each licensed health plan, and the results of the Department’s financial examinations in report-form style. The DMHC has also included a special section for our licensed health plans to access and download important information.

Submit Financial Reports

To help health care service plans meet the reporting requirements of Assembly Bill 1083 (Stats. 2012, Chap. 852), the Department has modified the existing reporting format of Report #4: Enrollment and Utilization Table of the reporting forms for the monthly, quarterly, and annual submission of financial statements.

The reporting forms (Version 9.0.0 for the Annual and Quarterly forms and Version 7.0.0 for the Monthly form) dated January 23, 2013 are required for any new submissions of the monthly, quarterly or annual financial statements; they are also to be used to revise previously filed statements. The only change made to the previous forms is to Report #4, as noted above. The “What are the changes?” link will show you the details of the changes made from the previous form.  The revised reporting forms, Version 9.0.0 for Annual and Quarterly and Version 7.0.0 for Monthly, dated January 23, 2013, are effective immediately.

If you have any further questions please contact healthplanreporting@dmhc.ca.gov or call 916-255-2443 or 916-255-2441.

Use the financial statements shown below, implemented on 12/31/2008, for annual, quarterly and monthly reports.

Use the AB1962 Dental Medical Loss Ratio Reporting Form shown below for annual dental MLR reporting.

Click the link shown below to upload financial statements through the Department's web portal, using your own login and password.

If you don't have access to the web portal, please see your web portal administrator to be added. If you are not sure who your administrator is, please contact the Office of Plan Licensing at 916-324-9046.  Provide comments and feedback at healthplanreporting@dmhc.ca.gov  regarding the reporting forms.

Resources

Financial Solvency Reports

On August 31, 2001, the Department of Managed Health Care's proposed regulations implementing the first phase of SB 260 (Speier- 1999) became effective. The regulations require plans to provide the Department with certain information relating to the risk a plan has assigned to its provider network.

Claims Settlement Practices and Dispute Resolution

The Claims Settlement Practices and Dispute Mechanisms Regulations were approved by the Office of Administrative Law on July 24, 2003, and are effective as of August 25, 2003. The Quarterly Claims Settlement Practices Report is required to be submitted for each licensed health care service plan. Health care service plans report claim information if the plan or any of its capitated providers has failed to timely reimburse at least 95% of complete claims with correct payment including interest and penalties due, that became payable during the reporting period.

The links below are to view the Annual Plan Claims Payment and Dispute Resolution Mechanism Report and the Quarterly Claims Settlement Practices Report. Also provided is a link to instructions for completing these reports. The reports were effective as of quarter 1, 2006. Please note the additional reporting requirements are effective as of the 4th quarter in 2006.

Assembly Bill 72

Assembly Bill (AB) 72 (Bonta, 2016), signed by the Governor on September 23, 2016, prohibits “surprise balance billing” of enrollees in most circumstances. Beginning July 1, 2017, if an enrollee receives covered services from a contracting health facility, at which, or as a result of which, the enrollee receives covered services from a noncontracting individual health professional, the enrollee should pay no more than the same cost sharing required if the services were provided by a contracted individual health professional.

Additionally, by July 1, 2017, each health care service plan, and any entity to which it delegates responsibility for payment of claims, shall provide to the DMHC all of the following:

  1. Data listing its average contracted rates for the plan for services most frequently subject to Section 1371.9 in each geographic region in which the services are rendered for the calendar year 2015;
  2. Its methodology for determining the average contracted rate for the plan for services subject to Section 1371.9. The methodology to determine an average contracted rate shall ensure that the plan includes the highest and lowest contracted rates for the calendar year 2015;
  3. The policies and procedures used to determine the average contracted rates.

The DMHC provides the following documents to assist health care service plans and delegated entities submit the information required to demonstrate compliance with
AB 72:

  1. Average Contracted Rate Filing Overview
  2. Attachment 1. Average Contracted Rate Data Worksheet Instructions
  3. Attachment 2. Average Contracted Rate Data Worksheet
  4. Attachment 3. Average Contracted Rate Methodology Checklist and Instructions
  5. Attachment 4. Policy and Procedure Instructions

The DMHC is required to hold a public meeting on the development of the standardized methodology for determining the average contracted rate paid to noncontracting providers. The meeting will be held in Sacramento on June 26, 2017, from 1:30 p.m. to 3:30 p.m. Seating is limited for in-person attendance and will be on a first-come-first-serve basis. Click here  to view the agenda, including information on how to join via webinar or conference line.

The purpose of the meeting is to solicit public input on the development of the standardized methodology for calculating the average contracted rate for the services most frequently subject to Health and Safety Code Section 1371.9. In addition, the DMHC will provide an update on the implementation of AB 72 and provide an opportunity for public discussion related to the establishment of the Independent Dispute Resolution Process (IDRP).

To view the presentation, click here.

Rate Filing (Premium Rate Review and Aggregate Rate Data)

Rate Review for Individual and Small Group Markets

Beginning January 1, 2011, health plans are required to submit rate filings to the Department of Managed Health Care (DMHC) pursuant to Senate Bill 1163 (Chapter 661, Statutes of 2010). All rate filing documents are to be submitted through the National Association of Insurance Commissioners’ System for Electronic Rate and Form Filing (SERFF).

Director’s Letter (Letter 3-K) was issued on December 2, 2010 to provide additional guidance to health plans regarding electronic rate filings.

For individual and small group products, health plans are required to submit, through SERFF, separate documentation for each of the categories listed below.

Director’s Letter (Letter 8-K) was issued on September 2, 2016 and amends May 24, 2011 and February 2, 2012 versions. This letter provides additional guidance to health plans regarding individual and small group premium rate filings and aggregate data submissions. This letter also provides guidance for large group aggregate rate information submissions discussed below.

Director’s Letter (Letter 11-K) was issued on July 2, 2012, to provide additional guidance to health plans regarding premium rate filings for individual policies sold through associations.

DMHC has released the following forms for submissions via the SERFF system:

Further guidance regarding rate filing and rate filing contents may be released later.

Rate Data for Large Group Market

Beginning October 1, 2016, health plans are required to submit aggregate rate information to the Department of Managed Health Care (DMHC) pursuant to Senate Bill 546 (Chapter 801, Statutes of 2015). All rate filing documents are to be submitted through the National Association of Insurance Commissioners’ System for Electronic Rate and Form Filing (SERFF). The large group aggregate rate information submitted by health plans is posted under Premium Rate Review.

Additionally, DMHC is required to hold a public meeting to discuss the large group aggregate rate information submitted to DMHC annually and to provide an opportunity for public discussion of the reasons for the changes in the rates, benefits, and cost sharing in the large group market.

Director’s Letter (Letter 3-K)  was issued on December 2, 2010 to provide additional guidance to health plans regarding electronic rate filings.

For large group products, health plans are required to submit, through SERFF, separate documentation for each of the categories listed below.

  • The information requested in California Health and Safety Code section 1385.07(d) that is required to be displayed on the Department of Managed Health Care’s website as well as the submitting health plan’s website.

Director's Letter (Letter 8-K)  was issued on September 2, 2016 and amends May 24, 2011 and February 2, 2012 versions to provide additional guidance to health plans regarding large group aggregate rate information submissions.

DMHC has released the following forms for submissions via the SERFF system:

Further guidance regarding rate filing and rate filing contents may be released later.