CA Plain-Language Rate Filing Disclosure — 2027 Small Group Plans
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This document discloses Western Health Advantage's 2027 rate filing details and aggregate allowed cost and trend assumptions for new and renewing California Small Group plans; it governs actuarial and rate-setting information relevant to the payer's small-group products.
No material clinical or coverage changes in this revision.
Allowed Costs and Trend Attribution
Allowed costs and trend attribution
Summary of allowed costs and trend attributions by service category for the most recently completed calendar year and projected trend drivers.
ALL of the following
- Medical Services + RX: $566.92 PMPM
- Medical Services: $450.42 PMPM
- Prescription Drugs (RX): $116.50 PMPM
- Capitation (professional): $152.39 PMPM
- Capitation (institutional): $262.03 PMPM
- Capitation (Other): $12.60 PMPM
- Other (Out-of-Area Claims): $23.41 PMPM
ALL of the following
- Overall projected Medical Services + RX trend: 7.0%
- Capitation components (professional/institutional/other) — trend decomposition: Use of services = 0.5%, Price inflation = 4.8%, Fees and risk = 0.0%, Overall = 5.3%
- Other (Out-of-Area Claims) trend decomposition: Use of services = 0.5%, Price inflation = 4.8%, Fees and risk = 0.0%, Overall = 5.3%
ALL of the following
- Because most medical services are paid via capitation, the Plan lacks detailed cost data in many categories and directly pays primarily for out-of-area emergencies and prescription drugs.
Coding and Trend Metrics
| No codes listed |
Payment Approach and Claims Responsibility
Capitation payment model — limited direct claim payments
The Plan pays a flat per-member-per-month capitation to contracted medical groups/IPAs for the vast majority of medical services; the Plan directly pays only out-of-area emergency claims and prescription drugs.
- Capitation covers most medical services provided by contracted medical groups/IPAs.
- Plan retains direct payment responsibility only for out-of-area emergency claims and prescription drug claims.
Key Definitions
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