Explanation of the Rate Increase — Molina Healthcare of South Carolina, Inc.
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This document explains Molina Healthcare of South Carolina's proposed premium rate increase effective January 1, 2026, including drivers of the change and the affected membership and product lines.
Proposed average rate change of 24.5% for continuing Molina members effective January 2025.
Projected medical loss ratio of 85.6%, exceeding the ACA minimum required loss ratio of 80.0%.
Medical inflation and changes in provider contracting are cited as contributors to a 9.3% increase in claims and regional rate changes.
Rate Drivers and Determinants
Rate drivers
Summary of factors influencing the proposed rates
ALL of the following
- Financial experience: Baseline claims and premium experience from 2024 South Carolina Marketplace business (2024 premium PMPM $651.37; allowed claims PMPM $510.97; risk transfer $55.25).
- Rate change: Average proposed rate change of 24.5% for 42,612 continuing members; member premium change range 0.1% to 40.8% depending on geography, metal tier, and age.
- Medical trend: Medical inflation increased claims by 9.3%; historical medical and pharmacy claims experience and prospective trend are primary contributors to the rate increase. Changes in provider contracting also contribute to regional rate changes.
- Benefit changes: Renewal of seven gold and silver plan offerings with minimal impact from benefit design changes on rates.
- Administration and profit: Total administrative expenses expected to increase, contributing approximately 0.2% to rates; targeted profit margin remains unchanged.
Coding & Key Metrics
| No codes listed |
Provider Notice & Filing Summary
Informational rate filing — no PA or denial policy changes
This filing is informational only: Molina's rate filing summarizes proposed premium changes and does not introduce any provider prior authorization requirements or changes to denial policies.
Key Definitions
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