California rate filing disclosure (Spanish) — allowed PMPM costs, trend assumptions and aggregated benefit categories
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Spanish-language California rate filing disclosure describing allowed PMPM costs, trend assumptions and aggregated benefit categories for Western Health Advantage individual plans effective Jan 1–Dec 31, 2026; applies to the payer's California rate filing information and affects plan premium filings and stakeholders reviewing the filing.
No material clinical or coverage changes in this revision.
Rate Filing Disclosure Elements
Rate filing disclosure elements
Reported items in the disclosure
Allowed PMPM by aggregated benefit category
- Services medical (allowed PMPM): $602.97
- Prescriptions (RX) (allowed PMPM): $105.94
- Services medical + RX (allowed PMPM): $708.91
- Professional capitation (allowed PMPM): $220.45
- Institutional capitation (allowed PMPM): $339.93
- Other capitation (allowed PMPM): $17.84
- Other out-of-network care (allowed PMPM): $24.74
Percent-of-Medicare or rate notes (where provided)
- Other out-of-network care: 140% of Medicare
- RX: 100% of Medicare
Trend attribution details by category
- Many categories show 0% attribution to service use, price inflation, charges and risk
- Capitation-related categories: 4.6% attributed to price/inflation (professional, institutional, other capitation)
- RX: 2.4% attributed to service use and 10.9% to price, combining to 13.5%
- Services medical + RX combined: 0.4% use, 5.6% price/inflation, 0% charges/risk, total 6.0%
Other disclosures and authority
- Justification for any excessive rate increase: N/A
- Legal citation: CA Health & Safety Code Section 1385.07(d)
Aggregated Benefit Categories & Trend
| Inpatient | PMPM: $0 |
| Outpatient (including emergency room) | PMPM: $0 |
| Prescription drugs | PMPM: $105.94; % of Medicare: 100% |
| Laboratory (non-inpatient) | PMPM: $0 |
| Radiology (non-inpatient) | PMPM: $0 |
| Professional capitation | PMPM: $220.45 |
| Institutional capitation | PMPM: $339.93 |
| Other capitation | PMPM: $17.84 |
| Other (OON care, consistent without URRT definition) | PMPM: $24.74; % of Medicare: 140% |
| Medical services | PMPM: $602.97 |
Capitation and Payment Notes
Capitación PMPM y excepciones de pago directo
Debito: El Plan paga una tasa fija por miembro por mes (capitación) a sus grupos médicos contratados/IPAs para la gran mayoría de los servicios médicos; el Plan solo paga directamente reclamos para emergencias y medicamentos recetados fuera del área.
- Capitación fija PMPM a grupos médicos contratados/IPAs para la mayor parte de los servicios.
- Pagos directos solamente para emergencias y para recetas fuera del área.
Key Terms
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