Submit Financial Filings and Reports

As required under the law, and in furtherance of its mission to protect consumers, the DMHC reviews the health plans’ financial and compliance information on an ongoing basis to ensure a financially stable health care delivery system.

The DMHC provides the tools health plans need to submit all of the appropriate financial and compliance filings and reports.

Submit Financial Reporting Forms

All health plans are required to report their periodic financial information using the DMHC Financial Reporting Forms, published on January 23, 2013 including any revisions to their previously filed DMHC Financial Reporting Forms. Please see the Financial Form General Information, Definition, and Instructions for more information.

If you have any further questions please contact healthplanreporting@dmhc.ca.gov or call 916-255-2443 or 916-255-2447.

The DMHC has released the following Reporting Form templates, instructions, and updates:

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

After completing the required DMHC Financial Reporting Form, please upload the financial reporting forms through the DMHC's web portal, using your own login and password.

If you need access to the DMHC’s web portal, please see your Administrator Account user. If you do not know who the Administrator Account user is, please contact the Office of Plan Licensing at 916-324-9046. 

Please provide comments and feedback at healthplanreporting@dmhc.ca.gov  regarding the reporting forms.

 

Resources

Financial Solvency Reports

Health plans are required to provide the DMHC with certain information relating to the risk assigned to their provider network on a quarterly and annual basis.

Claims Settlement Practices and Dispute Resolution

The Quarterly and Annual Claims Settlement Practices Reports are required to be submitted for each licensed health plan. Health plans report claim information if the plan or any of its capitated providers have 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 DMHC has released the following Annual Plan Claims Payment and Dispute Resolution Mechanism Report and the Quarterly Claims Settlement Practices Report templates and instructions:

Click the link below to view the summary of the Quarterly Claims Settlement Practices Report:

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:

  • 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;
  • 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;
  • 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 held a public meeting on the development of the standardized methodology for determining the average contracted rate paid to noncontracting providers on June 26, 2017.

The purpose of the meeting was 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 provided an update on the implementation of AB 72 and provided 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)

The DMHC issued the following letters to provide guidance to health plans regarding premium rate filings:

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

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.

Rate Review for Individual and Small Group Markets

Beginning January 1, 2011, health plans are required to submit rate filings to the 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).

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

The 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 and Prescription Drug Cost Data for Large Group Market

Beginning October 1, 2016, health plans are required to submit aggregate rate information to the DMHC pursuant to Senate Bill 546 (Chapter 801, Statutes of 2015). In addition, beginning October 1, 2018, health plans are required to submit specific prescription drug cost information to the DMHC pursuant to Senate Bill 17 (Chapter 603, Statutes of 2017). 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, the DMHC is required to hold a public meeting to discuss the large group aggregate rate information submitted to the 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.

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 DMHC’s website as well as the submitting health plan’s website.

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

SB 546 Reporting Documents

SB 17 Reporting Form to be included in the SB 546 Rate Data Filing 

Prescription Drug Cost Data for Commercial Plans

Beginning October 1, 2018, health plans are required to submit prescription drug cost information to the DMHC pursuant to Senate Bill 17 (Chapter 603, Statutes of 2017). All cost filing documents for commercial plans are to be submitted via the DMHC e-filing portal.

Additionally, the DMHC is required to aggregate the data that it receives from health plans and compile a report for the public and legislators that demonstrates the overall impact of prescription drug costs on health care premiums. Information specific to individual health plans is considered confidential and will be withheld from public disclosure.

The DMHC has released the following forms for submissions via the DMHC's e-filing portal:

For large group health care service plan contracts, SB 17 requires specific cost information regarding covered prescription drugs be filed through SERFF. The DMHC has created reporting forms and instructions for this submission that can be found in the above section, Rate and Prescription Drug Cost Data for Large Group Market.   

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