Individual market rate increase justification
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Documents WHA's justification for a rate change effective 2025-01-01 for its individual medical market membership and explains drivers of the change.
Requested rate change reflects required benefit changes from Covered California, updates to Milliman benefit relativity models, enhanced silver plan mandates, and changes in provider reimbursement levels.
Expense allocation methodology update produced an estimated composite rate impact of a 3.5% decrease from administrative expense changes.
Projected medical and pharmacy cost trends assumed at 4.5% over 2023 based on federal submissions, Milliman Trend Guidelines, and issuer judgment.
Rate Change Drivers and Justification
Rate drivers
Factors used to justify the requested rate change
ONE of
- Approximate individual market members impacted: ~15,500
Reported current enrollment impacted by the rate change
- Variation in increase by plan due to required benefit changes from Covered California
Covered California-mandated benefit changes had an upward impact
- Updates to Milliman benefit relativity models and enhanced silver plan mandates
- Changes in WHA provider reimbursement levels
Trend developed using federal filings, Milliman Trend Guidelines, and issuer judgment
Driven by updated allocation methodology reducing general admin
Financial Metrics and Assumptions
| No codes listed |
Provider Documentation & Action Items
Maintain complete documentation supporting the rate change
Document and retain the rate change justification materials, including the enrollment impact, financial PMPMs, trend assumptions, benefit change drivers, and admin allocation impacts cited in the filing. These materials must be available to support the 2025-01-01 rate change.
- Number of members impacted: approximately 15,500 (individual market) as reported in the filing.
- Reported PMPM metrics: Premium $663 → $741; Adjusted Claims $590 → $656; Margin $1 → $8 (per CA SRRT and 2024 estimate).
- Assumed medical and pharmacy trend: 4.5% over 2023.
- Drivers to document: Covered California‑mandated benefit changes, Milliman benefit relativity updates, enhanced silver plan mandates, and provider reimbursement level changes.
- Administrative expense allocation change and its estimated composite rate impact: 3.5% decrease.
Key Dates and Definitions
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