draft instructions - rates - serff ld rate & form … · web viewa rate filing must be filed...

Washington State SERFF Life and Disability Rate and Form Filing General InstructionsThese instructions apply to filing of rates for all major medical plans, stand-alone dental, and stand-alone vision plans.

TABLE OF CONTENTSRATING FILING INSTRUCTIONS............................................................................................................................ 5

I . GENERAL DISABILITY RATE FILINGS............................................................................................................... 5

I.A. FOR INFORMATION REGARDING SPEED TO MARKET TOOLS SEE THE FILE NAMED “SMT – RATES – GENERAL DISABILITY.”5

I.B. RATE FILING SUBMISSION REQUIREMENTS:....................................................................................................5I.B.1. If both a rate filing and form filing are required:.............................................................................5I.B.2. Rate filings may have multiple corresponding form filings..............................................................5I.B.3. A rate filing must be filed unless you are making changes or adding a rider to an approved from

filing that does not affect the rates.................................................................................................5I.B.4. Under the Rate/Rule Schedule tab in SERFF:...................................................................................5I.B.5. Under the Rate/Rule Schedule tab in SERFF:...................................................................................5I.B.6. Under the Supporting Documentation tab in SERFF:.......................................................................5I.B.7. Out-of-State Group (WAC 284-30-600)...........................................................................................5I.B.8. Association, Trust or Employer Groups domiciled in Washington State;.........................................6I.B.9. Discretionary Groups under RCW 48.21.010(2) for Accident Only, Disability Income or CHAMPVA:

........................................................................................................................................................6I.B.10.If you request a separate “not-for-public” rate filing per RCW 48.02.120(3),..................................6

I I . FOR DISABILITY ISSUERS: OUT-OF-STATE GROUPS: DENTAL ONLY AND VISION ONLY PLANS [WAC 284-30-600]............................................................................................................................................................. 7

II.A. SCOPE AND APPLICABILITY OF THIS SUB-SECTION:...........................................................................................7II.A.1. Applies to filings for:........................................................................................................................7

II.B. FOR INFORMATION ABOUT SPEED TO MARKET TOOLS SEE THE DOCUMENT NAMED “SMT – RATES – HEALTH DENTAL VISION – LARGE GROUP.”........................................................................................................................ 7

II.C. RATE FILING SUBMISSION REQUIREMENTS:....................................................................................................7II.C.1. Issuers must file a new submission. Previously approved form or rate filings cannot be re-opened

to modify contents or to have it apply to new groups.....................................................................7II.C.2. If you request a separate “not-for-public” rate filing per RCW 48.02.120 (3):.................................7II.C.3. In the not-for-public rate filing only:................................................................................................8II.C.4. Under the General Information Tab in SERFF..................................................................................8II.C.5. Under the Rate/Rule Schedule tab in SERFF:...................................................................................8II.C.6. Under the Supporting Documents...................................................................................................8

WAOIC LD RATE AND FORM GFI of 36 Draft as of 12-06-2018

Washington State Office of the Insurance CommissionerSERFF Life and Disability Rate and Form Filing General Instructions

I I I . FOR DISABILITY ISSUERS: FILING FOR DISCRETIONARY GROUP UNDER RCW 48.21.010(2) FOR DENTAL ONLY OR VISION ONLY COVERAGE......................................................................................................................... 9

III.A. SCOPE AND APPLICABILITY OF THIS SUB-SECTION:...........................................................................................9III.A.1. Applies to filings for Discretionary groups per RCW 48.21.010 (2)............................................9

III.B. ISSUERS MUST FILE A NEW SUBMISSION. PREVIOUSLY APPROVED FORM OR RATE FILINGS CANNOT BE RE-OPENED TO MODIFY CONTENTS OR TO HAVE IT APPLY TO NEW GROUPS...............................................................................9

III.C. RATE FILING SUBMISSION REQUIREMENTS:....................................................................................................9III.C.1. If you request some rate filing information to be proprietary per RCW 48.02.120 (3):....................9III.C.2. In the not-for-public rate filing only:................................................................................................9III.C.3. Issuers must file a new submission rate filing with a concurrent new form filing for each

discretionary group, regardless whether the group is an out-of-state group or not........................9III.C.4.Under the General Information Tab in SERFF:.................................................................................9III.C.5.Under the Rate/Rule Schedule tab in SERFF:.................................................................................10III.C.6.Under the Supporting Documentation tab in SERFF:.....................................................................10

IV . STOP LOSS RATE FILINGS............................................................................................................................ 10

IV.A. GENERAL INFORMATION......................................................................................................................... 10IV.A.1. Scope of Section by TOI in SERFF: H12.....................................................................................10IV.A.2. For information about Speed to Market Tools for health, dental only, and vision only large

group plan rate filings for see the file named “SMT - Rates - Stop Loss.”......................................10IV.A.3. Rate filing submission requirements:......................................................................................10

V. INDIVIDUAL AND SMALL GROUP RATE FILINGS...........................................................................................11

V.A. INDIVIDUAL AND SMALL GROUP HEALTH PLANS AND PEDIATRIC DENTAL PLANS FOR HCSCS, HMOS AND DISABILITY ISSUERS.............................................................................................................................................. 11V.A.1. Health Plans for Nongrandfathered Individual and Small Groups offered, Issued, or renewed on or

after January 1, 2019.....................................................................................................................12V.A.2. Pediatric Stand Alone Dental Plan for 2019 Plan Year...................................................................13

V.B. FOR GRANDFATHERED INDIVIDUAL AND SMALL GROUP HEALTH PLANS RENEWED ON OR AFTER JANUARY 1, 2014.....16V.C. INDIVIDUAL AND SMALL GROUP (NON-PEDIATRIC) DENTAL ONLY AND VISION ONLY PLANS FOR HCSCS AND DISABILITY

ISSUERS.............................................................................................................................................. 17

VI . LARGE GROUP: HEALTH PLANS, DENTAL ONLY, AND VISION ONLY PLANS...................................................18

VI.A. GENERAL INFORMATION......................................................................................................................... 18VI.B. FOR LARGE GROUP RATE FILINGS SUBMITTED UNDER RCW 48.43.733(1) AND WAC 284-43-6560(1): LARGE GROUP

RATES THAT ARE NOT NEGOTIATED AND ARE FILED BEFORE THE RATE SCHEDULE IS USED.........................................18VI.C. FOR LARGE GROUP NEGOTIATED RATE FILINGS SUBMITTED UNDER RCW 48.43.733(2) AND WAC 284-43-6560(2): 20

VI I . ASSOCIATION RATE FILINGS FOR HCSCS, HMOS AND DISABILITY ISSUERS...................................................22

VII.A. HEALTH PLANS FOR CLOSED POOL GRANDFATHERED ASSOCIATIONS OR CLOSED POOL MEMBER-GOVERNED GROUPS UNDER WAC 284-43-0330 (3), (4) AND (5).................................................................................22

VII.B.ASSOCIATION OR MEMBER-GOVERNED GROUP TO WHOM THE HEALTH PLAN IS ISSUED CONSTITUTES A TRUE EMPLOYER UNDER 29 U.S.C. § 1002(5) OF THE EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) OF 1974 UNDER WAC 284-43-0330(1), AND (2).................................................................................................................... 23

VII.C.PATHWAY 2 ASSOCIATION HEALTH PLANS (PLACEHOLDER).............................................................................24VII.D. DENTAL ONLY OR VISION ONLY PLANS FOR ASSOCIATION OR MEMBER-GOVERNED GROUPS...........................24

VI I I . MEDICARE SUPPLEMENT INSTRUCTIONS..........................................................................................26

VIII.A. GENERAL INFORMATION.................................................................................................................. 26



VIII.B. SUBMISSION REQUIREMENTS:............................................................................................................ 26

IX . LONG-TERM CARE INSTRUCTIONS............................................................................................................... 27

IX.A.1. General Information................................................................................................................27IX.A.2. Submission requirements:.......................................................................................................27

X. SHORT-TERM LIMITED DURATION MEDICAL PLAN INSTRUCTIONS...............................................................27

X.A. GENERAL INFORMATION......................................................................................................................... 27X.B. SUBMISSION REQUIREMENTS:.................................................................................................................. 27

FORM FILING INSTRUCTIONS............................................................................................................................. 28

XI . GENERAL DISABILITY FORM FILINGS........................................................................................................... 28

XI.A. SCOPE OF SECTION BY TYPE OF INSURANCE (TOI) IN SERFF: H05, H06, H07G, H07I, H08G, H08I, H09G, H14G, H15G, H17G, H18G, H18I, H19I, H19G, H23G, OR H23I........................................................................28

XI.B. FORM FILING SUBMISSION REQUIREMENTS:.................................................................................................28XI.B.1.If both a rate filing and form filing are required:...........................................................................28XI.B.2.If only a form filing is required you must state the reason you are not providing a corresponding

rate filing in the filing description..................................................................................................28XI.B.3.Under RCW 48.18.100, all forms that are part of the insurance contract must be filed. This

includes the application, policy forms and jackets, endorsements, and specifications pages (completed in John Doe fashion). You may attach supporting documentation (side by side or markup) for a specific form under the Supporting Documentation tab.........................................28

XI.B.4.Except for Credit Life and Credit Accident and Health Insurance, you do not have to file notices to policyholders unless they amend policy provisions........................................................................28

XI.B.5.You must list all filed forms on the Form Schedule tab, and enter form numbers correctly...........28XI.B.6.Each form must have a unique identifying number and a way to distinguish it from new forms.. 29XI.B.7.Disability forms must be in not less than 10-point type.................................................................29XI.B.8.Single Case Filing submissions. For each unique group master application and/or group

enrollment form filed for review you must file a completed and signed “Custom Enrollment/Application Certification” on the Supporting Documentation tab. The custom applications and enrollment forms filed for review must be attached, in final form, on the Form Schedule tab. You must complete the Form Name field using the following naming convention: “Custom App/Enr [ABC Company].” “ABC Company” means the specific group, trust, association, etc.................................................................................................................................................29

XI.B.9.Out-of-State Groups [WAC 284.30.600]........................................................................................29XI.B.10. Association, Trust, or Employer Groups domiciled in Washington State.................................30XI.B.11. Discretionary Groups under RCW 48.21.010(2) for Accident Only, Disability Income or

CHAMPVA and Discretionary Groups under RCW 48.24.027(1) for group life and group annuities.30

XI.B.12. Must file in compliance with the provisions under RCW 48.21.010 (2) (a) and (b) or RCW 48.24.027(1), (2) and (3) and all applicable filing instructions of rate and form filings.................30

XI.B.13. Small Business Retirement System filings (ESSB 5826) for consideration under this program, the filing must contain:..................................................................................................................31

XI.B.14. Life Insurance and Charitable Gift Annuity Forms...................................................................31

XI I . LONG TERM CARE FORMS........................................................................................................................... 34

XII.A.LONG TERM CARE ADVERTISING MUST BE SUBMITTED ON AN LTC06-OTHER TOI CODE........................................34XII.B.REQUIREMENTS FOR LONG-TERM CARE PARTNERSHIP FILINGS.........................................................................34



XI I I . MEDICARE SUPPLEMENT FORMS...................................................................................................... 35

XIII.A. SCOPE OF SECTION BY TYPE OF INSURANCE (TOI) IN SERFF: MS02G, MS02I, MS04G, MS04I, MS05G, MS05I, MS07G, MS07I, MS08G, MS08I..............................................................................................35

XIII.B. REPORTS SUCH AS REFUND CALCULATIONS, MULTIPLE POLICY REPORTS AND GRIEVANCE REPORTS ARE NOT BEING ACCEPTED THROUGH SERFF. PLEASE SEE THE INSTRUCTIONS FOR SUBMITTING THESE REPORTS AT HTTPS://WWW.INSURANCE.WA.GOV/INSTRUCTIONS-FILING-MEDICARE-SUPPLEMENT-ANNUAL-REPORTS...................35

XIII.C. SUBMISSION REQUIREMENTS:........................................................................................................... 35

XIV. YOUR FILING IS INCOMPLETE AND WILL BE REJECTED IF:...................................................................35

XV. REJECTED FILINGS WILL NOT BE RE-OPENED...............................................................................................36

XVI . SERFF OBJECTION LETTER RESPONSE REQUIREMENTS FOR RATE FILINGS..........................................36

XVI I . TO REQUEST TO MAKE A CHANGE TO A RATE FILING AFTER IT HAS BEEN ACCEPTED FOR REVIEW; DIRECTION FOR PERMISSION TO AMEND FILINGS UNDER WAC 284-43-0200...............................................36

XVI I I . AFTER A FINAL DISPOSITION BY OIC ANALYST...................................................................................36

XIX. CONTACT US.................................................................................................................................... 37



INSTRUCTIONSRating Filing InstructionsI. General Disability Rate Filings

Scope of Section by Type of Insurance (TOI) in SERFF: H05, H06, H07G, H07I, H08G, H08I, H09G, H14G, H15G, H17G, H18G, H18I, H19I, H19G, H23G, or H23I

I.A. For Information regarding Speed to Market Tools see the file named “SMT – Rates – General Disability.”

I.B. Rate filing submission requirements:

I.B.1. If both a rate filing and form filing are required:(a) All of the applicable filings must be submitted concurrently.(b) The Corresponding Filing Tracking Number field must include the

appropriate tracking numbers for each filing.

I.B.2. Rate filings may have multiple corresponding form filings.

I.B.3. A rate filing must be filed unless you are making changes or adding a rider to an approved from filing that does not affect the rates.

I.B.4. Under the Rate/Rule Schedule tab in SERFF:(a) For rate change filings, please make it clear in the filing description

you are filing a rate change for an existing product.

I.B.5. Under the Rate/Rule Schedule tab in SERFF:(a) List all the form numbers to which the rate filing is applicable in the

affected form numbers section.

I.B.6. Under the Supporting Documentation tab in SERFF:(a) Include all supporting documentation and justification.

I.B.7. Out-of-State Group (WAC 284-30-600)(a) Issuers must file a new submission. Previously approved rate filings

cannot be re-opened to modify contents or to have it apply to new groups.

(b) Under the General Information Tab in SERFF: (i) In the SERFF Product Name field, the product name must start with

“Out of State Group [Group Name].”(ii) In the Filing Descriptions field, state that the filing is an out-of-state

group filing.(c) You must file a rate filing for each out-of-state group unless:



(i) You are filing a rider specific to the group and that rider does not affect the rates; or

(ii) You have already filed a rate for the association or trust and the changes in the form filing do not affect the rates.

I.B.8. Association, Trust or Employer Groups domiciled in Washington State;(a) Separate rate filings must be filed for each association or trust.(b) For the association or trust:

(i) In the SERFF Product Name field, the product name must start with “In State Group [Name of Association or Trust]”

(c) For single employers:(i) In the SERFF Product Name field, the product name must start with

“In State Group [Name of Group].”(d) You must file a rate filing for each group domiciled in Washington

State unless:(i) You are filing a rider specific to the group and that rider does not

affect the rates; or(ii) You have already filed a rate for the association or trust and the

changes in the form filing do not affect the rates.

I.B.9. Discretionary Groups under RCW 48.21.010(2) for Accident Only, Disability Income or CHAMPVA:

(a) Must file a new rate filing concurrently with the form for each discretionary group whether the group is an out-of-state group or not. Previously approved form or rate filings cannot be re-opened to modify contents.

(b) In the SERFF Product Name filed, the product name must start with “Discretionary Group [Group Name].”

(c) Must disclose in the Filing Description field that you are filing for a discretionary group under the requirements of RCW 48.21.010(2)

(d) You must file a rate filing for each discretionary group unless:(i) You are filing a rider specific to the group and that rider does not

affect the rates; or(ii) You have already filed a rate for the association or trust and the

changes in the form filing do not affect the rates.

I.B.10. If you request a separate “not-for-public” rate filing per RCW 48.02.120(3),

(a) You must provide one public rate filing, and one not-for-public rate filing. Not-for-public rate filings are subject to the same instructions as for-public rate filings except as described below.

(b) In the not-for-public filing(i) State clearly in SERFF Product Name Field under General

Information tab “not-for-public.”



(ii) In the SERFF Filing Description, on the General Information tab, provide your justification of requesting certain documents to be not-for-public per RCW 48.02.120(3), including a list of documents not included in the public rate filing.

(iii) Include supporting documentation and justification in the public filing that is subject to public inspection.

(iv) Include any additional documentation that is not-for-public inspection in the Supporting Documentation tab.

II. For Disability Issuers: Out-of-State Groups: Dental only and Vision only plans [WAC 284-30-600]

II.A. Scope and applicability of this sub-section:

II.A.1. Applies to filings for:(a) Large out-of-state group (both association and non-association

dental only plans, and (b) Large out-of-state group (both association and non-association)

vision only plans.

II.B. For information about Speed to Market Tools see the document named “SMT – Rates – Health Dental Vision – Large Group.”

(a) This and related documents are provided on the OIC’s website.

II.C. Rate Filing submission requirements:

II.C.1. Issuers must file a new submission. Previously approved form or rate filings cannot be re-opened to modify contents or to have it apply to new groups.

II.C.2. If you request a separate “not-for-public” rate filing per RCW 48.02.120 (3):

(a) You must provide one public rate filing and one not-for-public rate filing.

(b) State clearly in SERFF Product Name Filed under General Information tab in SERFF “public” rate or “not-for-public” rate.

(c) Both public and not-for-public rate filings must follow the instructions in this section except where stated otherwise.

(d) Include only supporting documentation in the public filing that is subject to public inspection.

II.C.3. In the not-for-public rate filing only:(a) In the SERFF Filing Description, on the General Information tab,

provide your justification of requesting certain documents to be not-for-public per RCW 48.02.120(3), including a list of documents not included in the public rate filing.



(b) Include all not-for-public documentation and justification on the Supporting Documentation tab

II.C.4. Under the General Information Tab in SERFF(a) In the SERFF Product Name field, use “Out of State Group – [Group

Name] – [[Public] or [Not-for-Public]]”(i) Replace [Group Name] in the above naming convention with the

actual group’s name.(ii) Choose to include “for-public” or “not-for-public” but not both in the

above naming convention.(b) In the Submission Type field, indicate the type of submission.(c) In the Corresponding Filing Tracking Number field, indicate all

applicable SERFF Tracking IDs for the corresponding form filings for new plans and for the most recent corresponding rate and form filing for existing plans.

(d) In the Filing Description field state that this is an out-of-state group filing.

II.C.5. Under the Rate/Rule Schedule tab in SERFF:(a) Attach applicable group information and rate schedules. [WAC 284-

43-6560(5), WAC 284-43-6580](i) See the speed to market tools referenced at the beginning of this

section for helpful guidance, recommended template, and illustrative examples related to this item.

(b) List the rate action as “revised” for all renewal filings and “new” for all filings with no rate history.

II.C.6. Under the Supporting Documents(a) Complete and attach Filing Summary under WAC 284-43-6540.

(i) Name the file “WAC 284-43-6540.”(ii) For an Excel version of the WAC 284-43-6540 form see the speed to

market tools referenced at the beginning of this section. (b) Attach all other supporting documents.

III. For Disability Issuers: Filing for Discretionary Group under RCW 48.21.010(2) for Dental Only or Vision only coverage.

III.A. Scope and applicability of this sub-section:

III.A.1. Applies to filings for Discretionary groups per RCW 48.21.010 (2)

III.B. Issuers must file a new submission. Previously approved form or rate filings cannot be re-opened to modify contents or to have it apply to new groups.

III.C. Rate filing submission requirements:



III.C.1. If you request some rate filing information to be proprietary per RCW 48.02.120 (3):

(a) You must provide one public rate filing and one not-for-public rate filing.

(b) State clearly in SERFF Product Name Filed under General Information tab in SERFF “public” rate or “not-for-public” rate.

(c) Both public and not-for-public rate filings must follow the instructions in this section except where stated otherwise.

(d) Include only supporting documentation in the public filing that is subject to public inspection.

III.C.2. In the not-for-public rate filing only:(a) In the SERFF Filing Description, on the General Information tab,


(b) Include all not-for-public documentation and justification on the Supporting Documentation tab.

III.C.3. Issuers must file a new submission rate filing with a concurrent new form filing for each discretionary group, regardless whether the group is an out-of-state group or not.

III.C.4. Under the General Information Tab in SERFF:(a) In the SERFF Product Name field, use “Discretionary Group – [Group

Name] – [[Public] or [Not-for-Public]]”(i) Replace [Group Name] in the above naming convention with the

actual group’s name.(ii) Choose to include “for-public” or “not-for-public” but not both in the

above naming convention.(b) In the Submission Type field, indicate the type of submission.(c) In the Corresponding Filing Tracking Number field, indicate all

applicable SERFF Tracking IDs for the corresponding form filings for new plans and for the most recent corresponding rate and form filing for existing plans.

(d) In the Filing Description field state that this is a discretionary group filing.

III.C.5. Under the Rate/Rule Schedule tab in SERFF:(a) Attach applicable rating information and rate schedules. (b) List the rate action as “revised” for all renewal filings and “new” for

all filings with no rate history.

III.C.6. Under the Supporting Documentation tab in SERFF:(a) Attach all other supporting documents.



IV.Stop Loss Rate FilingsIV.A. General Information

IV.A.1. Scope of Section by TOI in SERFF: H12

IV.A.2. For information about Speed to Market Tools for health, dental only, and vision only large group plan rate filings for see the file named “SMT - Rates - Stop Loss.”

(a) This and related documents are provided on the OIC’s website.

IV.A.3. Rate filing submission requirements:(a) If you request some rate filing information to be proprietary per

RCW 48.02.120(3):(i) You must provide one public rate filing and one not-for-public rate

filing.(ii) State clearly in SERFF Product Name Field under General

Information tab in SERFF: “public” rate or “not-for-public” rate.(iii) Both public and not-for-public rate filings must follow the

instructions in this section except where stated otherwise. (iv) Include only supporting documentation in the public filing that is

subject to public inspection.(v) In the not-for-public rate filing only:

1. In the SERFF Filing Description, on the General Information tab, provide your justification of requesting certain documents to be not-for-public per RCW 48.02.120(3), including a list of documents not included in the public rate filing.

2. Include all not-for-public documentation and justification on the Supporting Documentation tab

(b) Under the General Information Tab in SERFF(i) In the SERFF Product Name field, use one of the following product

naming conventions.1. For rate filings that include a rate manual use “Rate Manual –

[Rate Manual Identifier] – [[New] or [Update]] – [[for-public] or [not-for-public]].”1.1Replace “[Rate Manual Identifier]” with a short descriptive

identifier for the rate manual.1.2Choose “New” in the above naming conventions if this is a

new product to be offered in Washington State. Otherwise, choose “Update.”

2. For rate filings with rates for one specific group use “Group Specific Rates – [Group Name] - [[for-public] or [not-for-public]].”2.1Replace “[Group Name]” in the above naming conventions

with the name of the group.(ii) In the Implementation Date Requested field, state a requested

effective date or state “On Approval.”



(iii) In the Submission Type field, indicate the type of submission.(iv) In the Overall Rate Impact field, state the average rate change

percentage.(v) In the Corresponding Filing Tracking Number field, state all

applicable SERFF Tracking IDs for the corresponding rate and form filings. If the filing includes changes for a previously filed rate manual, include the SERFF Tracking number for the last rate filing.

(c) Under the Rate/Rule Schedule tab in SERFF:(i) Attach the rates, rate schedules, and rate manuals.

1. Attach these documents in PDF file format.2. You may attach an Excel versions; however, it must be a

duplicate of the PDF version and include “Duplicate.xlsx” at the end of the file name.

(ii) List the rate action as “revised” for all renewal filings and “new” for all filings with no rate history.

(d) Under the Supporting Documents(i) Attach an actuarial memorandum and certification.(ii) Attach all other supporting documents.

V. Individual and Small Group Rate FilingsV.A. Individual and Small Group Health Plans and Pediatric Dental Plans

for HCSCs, HMOs and Disability Issuers

V.A.1. Health Plans for Nongrandfathered Individual and Small Groups offered, Issued, or renewed on or after January 1, 2019(a) Scope of Section by Type of Insurance (TOI) in SERFF: H16I, HOrg02I,

H16G, or HOrg02G.(b) Public Information: All rate filings submitted under this section are

for-public rate filings. [RCW 48.02.120(4)] (c) For information regarding Speed to Market Tools

(i) For individual and small group health plan rate filings see the file named “SMT – Rates – Health – Individual and Small Group.”

(ii) For individual and small group health plan binder filings see the file named “SMT – Binder – Health – Individual and Small Group.”

(iii) These and related documents are provided on the OIC’s website (Insert link).

(d) Submission Requirements:(i) Under the General Information tab in SERFF:

1. In the SERFF Product Name field, the product name must start with “2019 nongrandfathered [individual or small group].”

2. In the Corresponding Filing Tracking Number field, list all the SERFF Tracking Numbers of the corresponding form filings.

3. Properly complete the “Exchange Intentions” field.(ii) Under the Rate/Rule Schedule tab in SERFF:



1. New or Revised field:1.1 If you offered plans in the previous plan year, select

“Revised.”1.2 Otherwise, select “New.”

2. Include a complete rate schedule.2.1 If you choose to include both an Excel file format and PDF

format, include the word “duplicate” in Excel file name.2.2 See speed to market tools referenced at the beginning of

this section for further guidance related to this item.3. All other supporting documentation and information should be

attached under the Supporting Documentation tab. 4. List the affected form number for each plan.5. You must check the box “Add Rate Data” and populate all fields

(including Product ID and HIOS Submission ID) with accurate data. For a new carrier, you may populate only the mandatory fields.

(iii) Under the Supporting Documentation tab in SERFF:1. Parts I, II, and III requirements per RCW 48.02.120(5), and 45

CFR 154.215, 154.225, 147.102, and 156.80.1.1 Attach in PDF and in Excel format, Part I Unified Rate Review

Template (URRT).1.1.1The PDF file must be the PDF version of the Excel file. 1.1.2You must name the Part I PDF file “Part I Unified Rate

Review Template” and the Excel file “Part I Unified Rate Review Template Duplicate.xlsx”

1.2 Attach in PDF format, Part II Written Description Justifying the Rate Increase. 1.2.1You must name the Part II PDF file “Part II Written

Description Justifying the Rate Increase”1.3 Attach in PDF format, Part III Rate Filing Documentation and

Actuarial Memorandum as set forth by the US Department of Health and Human Services regulations under 45 CFR Part 154.1.3.1You must name the Part III PDF file “Part III Rate Filing

Documentation and Actuarial Memorandum.”2. Complete and attach the individual and small group rate filing

summary under WAC 284-43-6660.2.1 Name the file(s) “WAC 284-43-6660.” If you choose to

include both an Excel file format and PDF format, include the word “duplicate” in Excel file name.

2.2 For an Excel version of the WAC 284-43-6660 form see the speed to market tools referenced at the beginning of this section.

(e) Your individual or small group rate filing will be rejected if any of the following conditions exist:



(i) ”Filings not timely submitted will be rejected without review.” [WAC 284-43-0200]

(f) Rejected Filings will not be Re-Opened(i) If the OIC Technical Support Unit rejects your filing, you must submit

a new filing following the procedures in our Rejection Notice and the General Filing Instructions.

V.A.2. Pediatric Stand Alone Dental Plan for 2019 Plan Year(a) Scope of Section by TOI in SERFF: H10I.001 or H10G.001

(i) For stand-alone dental plan rate filings, issuers are required to submit only one public rate filing and one not-for-public rate filing (if applicable) per (individual or small group) market.

(b) For information regarding Speed to Market Tools(i) For individual and small group Stand Alone Pediatric Dental rate

filings see the file named “SMT – Rates – SAPD – Individual and Small Group.”

(ii) For individual and small group Stand Alone Pediatric Dental binder filings see the file named “SMT – Binder – SAPD – Individual and Small Group.”

(iii) These and related documents are provided on the OIC’s website (Insert link).

(c) Submission Requirements for all stand-alone dental plans that provide pediatric dental benefits as one of the essential health benefits (EHBs):

(i) Under the General Information Tab in SERFF:1. The Product Name in SERFF must start with one of the following

naming conventions to describe your rate filing for the market:1.1 “Individual-EHB Dental-Both Inside and Outside Exchange –

[public or not-for-public]1.2 “Individual-EHB Dental-Exchange Only – [public or not-for-

public]1.3 “Individual-EHB Dental-Outside Exchange Only – [public or

not-for-public]1.4 “Small Group-EHB Dental-Both Inside and Outside Exchange

– [public or not-for-public]1.5 “Small Group-EHB Dental-Exchange Only – [public or not-for-

public]1.6 “Small Group-EHB Dental-Outside Exchange Only – [public or

not-for-public]1.7 If you have various plans that include inside Exchange only

plans and Outside Exchange only plans, use the naming convention in either 1.1 or 1.4 above,

2. In the Corresponding Filing Tracking Number field, list all the SERFF Tracking Numbers of the corresponding form filings and the corresponding rate filing (if you request a separate not-for-public rate filing).



(ii) In the public rate filing,1. Under the General Information tab in SERFF:

1.1 In the Filing Description section:1.1.1If the company is requesting a separate not-for-public

rate filing state “the company is requesting a separate not-for-public rate filing.”

2. Under the Rate/Rule Schedule tab in SERFF:2.1 New or Revised field:

2.1.1If you offered plans in the previous plan year, select “Revised.”

2.1.2Otherwise, select “New.”2.2 List the affected form number for each plan.2.3 Include a complete rate schedule.

3. Under the Supporting Documentation tab in SERFF:3.1 Attach an actuarial certification as required by 45 CFR

§156.150. 3.2 Complete and attach a filing summary under WAC 284-43-

6660.3.2.1Name the file(s) “WAC 284-43-6660.” If you choose to


3.2.2For an Excel version of the WAC 284-43-6660 form see the speed to market tools referenced at the beginning of this section.

3.3 Include all other supporting documentation and justification that is subject to public inspection.

(iii) If you request a separate “not-for-public” rate filing per RCW 48.02.120(3),1. You must provide one public rate filing, and one not-for-public

rate filing. Not-for-public rate filings are subject to the same instructions as for-public rate filings except as described below.

2. In the not-for-public filing2.1 State clearly in SERFF Product Name Field under General

Information tab “not-for-public.”2.2 In the SERFF Filing Description, on the General Information

tab, provide your justification of requesting certain documents to be not-for-public per RCW 48.02.120(3), including a list of documents not included in the public rate filing.

2.3 Include supporting documentation and justification in the public filing that is subject to public inspection.

2.4 Include any additional documentation that is not-for-public inspection in the Supporting Documentation tab.

(d) Your stand-alone dental rate filing will be rejected if any of the following conditions exist:



(i) ”Filings not timely submitted will be rejected without review.” [WAC 284-43-0200]



V.B. For Grandfathered Individual and Small Group Health Plans Renewed on or after January 1, 2014(a) Scope of Section by TOI in SERFF: H16I, HOrg02I, H16G, or HOrg02G.(b) For information regarding Speed to Market Tools for individual and

small group health plan rate filings see the file named “SMT – Rates – Health – Individual and Small Group.”

(i) This and related documents are provided on the OIC’s website (Insert link).

(c) Submission Requirements for all individual and small group rate filings, you must:

(i) Under the Rate/Rule Schedule tab in SERFF:1. New or Revised field:

1.1 If you offered plans in the previous plan year, select “Revised.”

1.2 Otherwise, select “New.”2. Include a complete rate schedule.

2.1 All supporting documentation and information should be attached to the Supporting Documentation tab.

3. List the affected form number for each plan.4. Check the box to “Add Rate Data” and populate all fields with

accurate data for the public filing. Do not check the box to “Add Rate Data” for the not-for-public filing.

(ii) Under the Supporting Documentation tab in SERFF:1. Attach in PDF format and in Excel format, the Part I Unified Rate

Review Template. [RCW 48.02.120(5)]1.1 For Part I Unified Rate Review Template, the PDF file must

include the PDF version of the Excel file. Name the Part I PDF file “Part I Unified Rate Review Template” and the Excel file “Part I Unified Rate Review Template Duplicate.xlsx”

2. Attach in PDF format, the Part II Written Description Justifying the Rate Increase. [RCW 48.02.120(5)]2.1 Name the Part II PDF file “Part II Written Description

Justifying the Rate Increase.”3. Attach in PDF format the Part III Actuarial Memorandum. [RCW

48.020120(5)]3.1 Name the Part III PDF file “Part III Rate Filing Documentation

and Actuarial Memorandum.”4. Attach a completed the individual and small group rate filing

summary under WAC 284-43-6660.4.1 Name the file(s) “WAC 284-43-6660.” If you choose to




4.2 For an Excel version of the WAC 284-43-6660 form see the speed to market tools referenced at the beginning of this section.

V.C. Individual and Small Group (Non-Pediatric) Dental Only and Vision Only Plans for HCSCs and Disability Issuers(a) Scope of Section by TOI in SERFF: H10I, H10G, H20I, or H20G.(b) This section applies to plans which are not intended to provide the

Pediatric Essential Health Benefits for oral care or vision.(c) For information regarding Speed to Market Tools see the file

named “SMT - Rates - Non-SAPD - Individual and Small Group Dental Guidance.”

(i) These and related documents are provided on the OIC’s website (Insert link).

(d) Submission Requirements: (i) Under the General Information tab in SERFF:

1. In the SERFF Product Name Field, 1.1 Start the product name with one of the following naming

conventions:1.1.1Filings for rate changes only: “Individual Dental Pool –

Rate Changes only”1.1.2Filings for rate Changes and adding new plans:

“Individual Dental Pool – Rate Changes with New Plans”1.1.3Filings for new plans only: “Individual Dental – New

Plans only”1.2 Replace “Individual” with “Small Group,” and “Dental” with

“Vision” in the above naming conventions were appropriate.1.3 If the filing is a public filing, include “public”; otherwise,

state “not-for-public”.2. In the Filing Description of the General Information tab in SERFF:

2.1 Indicate whether the rate filing includes rates for new plans only, existing plans only, or both new and existing plans. List the plan name for each new plan, and the plan name and average rate change for each of the renewal plans.

3. In the Corresponding Filing Tracking Number field, provide all applicable SERFF Tracking IDs for the corresponding concurrent form filings for new plans and for the most recent corresponding rate and form filings for existing plans.

4. Under the Supporting Documentation tab in SERFF:4.1 Attach a completed the individual and small group rate filing

summary under WAC 284-43-6660.4.1.1Name the file(s) “WAC 284-43-6660.” If you choose to




4.1.2For an Excel version of the WAC 284-43-6660 form see the speed to market tools referenced at the beginning of this section.

(ii) If you request certain documents to be not-for-public per RCW 48.02.120(3):1. You must provide one public rate filing, and one not-for-public

rate filing. State clearly in SERFF Product Name: “public” or “not-for-public”.

2. Both public and not-for-public rate filings must include public rates and follow filing instructions. Include only supporting documentation and justification in the public filing that is subject to public inspection.

3. In the not-for-public rate filing only:3.1 In the SERFF Filing Description, on the General Information

tab, provide your justification of requesting certain documents to be not-for-public per RCW 48.02.120(3), including a list of documents not included in the public rate filing.

3.2 Include all not-for-public documentation and justification under the Supporting Documentation tab.

VI.Large Group: Health Plans, Dental Only, and Vision Only Plans

VI.A. General Information(a) Scope of Section by TOI in SERFF: H16G, HOrg02G, H10G, or H20G.(b) For each non-association large group, the group’s rates can be filed

utilizing one of the following two methods – rates are filed before the rate schedule is used or rates are filed as negotiated rates (either rates are negotiated or the corresponding contract forms are negotiated). You can use both filing methods but you cannot mix and match these two methods in the same rate filing. For association rate filings, see Association Section.

(c) For information about Speed to Market Tools for health, dental only, and vision only large group plan rate filings for see the file named “SMT – Rates – Health Dental Vision – Large Group.”


VI.B. For large group rate filings submitted under RCW 48.43.733(1) and WAC 284-43-6560(1): Large group rates that are not negotiated and are filed before the rate schedule is used.(a) Scope and applicability of this sub-section:



This sub-section applies to health plans, dental only, and vision only coverage for non-association large groups where rates are set through standard rating methodology and filed before the rate schedule is used. For association filings see Association sections.

(b) If you request some rate filing information to be proprietary per RCW 48.02.120(3):

(i) You must provide one public rate filing and one not-for-public rate filing.

(ii) State clearly in SERFF Product Name Field under General Information tab in SERFF: “public” rate or “not-for-public” rate.

(iii) Both public and not-for-public rate filings must follow the instructions in this section except where stated otherwise.

(iv) Include only supporting documentation in the public filing that is subject to public inspection.

(v) In the not-for-public rate filing only:1. In the SERFF Filing Description, on the General Information tab,



(c) Rate filing submission requirements(i) Under the General Information Tab in SERFF

1. In the SERFF Product Name field, use “Large Group Rate Manual – [Rate Manual Identifier] – [[for-public] or [not-for-public]].”

1.1.1Replace “[Rate Manual Identifier]” with a short descriptive identifier for the rate manual. This should distinguish the rate manual from other rate manuals the company may file.

1.1.2Include either “for-public” or “not-for-public” in the above naming convention.

2. In the Implementation Date Requested field, state a requested effective date or state “On Approval.”

3. In the Submission Type field, indicate the type of submission.4. In the Overall Rate Impact field, state the average rate change

percentage.5. In the Corresponding Filing Tracking Number field, state all

applicable SERFF Tracking IDs for the corresponding rate and form filings. If the filing includes changes for a previously filed rate manual, include the SERFF Tracking number for the last rate filing.

(ii) Under the Rate/Rule Schedule tab in SERFF:1. Attach the rates and rate schedules. [WAC 284-43-6520(10) and

(11), WAC 284-43-6560(1), WAC 284-43-6580]1.1 Attach these documents in PDF file format.



1.2 You may attach an Excel versions; however, it must be a duplicate of the PDF version and include “Duplicate.xlsx” at the end of the file name.

2. List the rate action as “revised” for all renewal filings and “new” for all filings with no rate history.

(iii) Under the Supporting Documents1. Complete and attach Filing Summary under WAC 284-43-6540.

1.1 Name the file “WAC 284-43-6540.pdf.”1.2 For an Excel version of the WAC 284-43-6540 form see the

speed to market tools referenced at the beginning of this section.

2. Attach all other supporting documents.

VI.C. For large group negotiated rate filings submitted under RCW 48.43.733(2) and WAC 284-43-6560(2):(a) Scope and applicability of this sub-section:

This sub-section applies health plans, dental only, and vision only coverage for non-association large groups or where “rates” are connected to a negotiated contract form and via negotiation with the group [WAC 284-43-6520(8) and (11); WAC 284-43-6560(2), (3), and (4)]:

(b) If you request some rate filing information to be proprietary per RCW 48.02.120(3):








(c) Rate filing submission requirements(i) Select the correct Type of Insurance (TOIs and Sub-TOIs) for the

coverage:1. For major medical coverage use H16G.002C.

1.1 This type of filing includes major medical coverage. The filing can also include dental or vision coverage when a group purchases medical, and dental or vision coverage from the company.



2. If the group does not purchase major medical plan, for dental only coverage use H10G.000. 2.1 These filings only include dental only coverage.

3. If the group does not purchase major medical plan, for vision only coverage use H20G.3.1 These filings only include vision only coverage.

(ii) Under the General Information Tab in SERFF1. In the SERFF Product Name field, use one of the following

naming conventions:1.1 For a negotiated rate filing that includes rates for multiple

large groups, use “Multiple Large Group Negotiated Rate Filing – New and Renewing [Rates Effective Date] – [[for-public] or [not-for-public]].”

1.1.1Replace [Rates Effective Date] with the common effective date for the rates. All rates for multiple groups included in one rate filing must have the same effective date.

1.1.2Include either “for-public” or “not-for-public” in the above naming convention.

1.1.3See the speed to market tools referenced at the beginning of this section for helpful guidance, recommended template, and illustrative examples related to this filing methodology.

1.2 For a negotiated rate filing that includes rates only for a single group, use “Large Group Negotiated Rate Filing – [Group Name] – [[for-public] or [not-for-public]].”

1.2.1Replace [Group Name] with the group’s name.1.2.2Choose to include “for-public” or “not-for-public” but

not both in the above naming convention.1.2.3See the speed to market tools referenced at the

beginning of this section for helpful guidance, recommended template, and illustrative examples related to this filing methodology.

2. In the Implementation Date Requested field, state the effective date of the rates. 2.1 For multiple group negotiated filings, the effective date in

this field must match the effective date stated in the SERFF product name for multiple group negotiated filings.

3. In the Submission Type field, indicate the type of submission.4. In the Overall Rate Impact field, if this is not a new group, state

the average rate change percentage.5. In the Corresponding Filing Tracking Number field,

5.1 For a multiple group rate filing, state the corresponding for-public and not-for-public rate filing SERFF tracking numbers if applicable.



5.2 For a single group rate filing, state all applicable SERFF Tracking IDs for the rate filing and the corresponding form filing if applicable.

(iii) Under the Rate/Rule Schedule tab in SERFF:1. Attach all group information and rate schedules.

1.1 See the speed to market tools referenced at the beginning of this section for helpful guidance, recommended template, and illustrative examples related to this item.

2. List the rate action as “revised” for filings that include renewal groups and “new” for filings with no rate history or only new groups.

(iv) Under the Supporting Documents1. Complete and attach Filing Summary under WAC 284-43-6540

for each rate filing, regardless of filing for multiple large groups, a single large group, new groups, or renewing groups. [WAC 284-43-6580]1.1 Name the file “WAC 284-43-6540.pdf.”1.2 For an Excel version of the WAC 284-43-6540 form see the



VII. Association Rate Filings for HCSCs, HMOs and Disability Issuers

VII.A. Health Plans for Closed Pool Grandfathered Associations or Closed Pool Member-Governed Groups under WAC 284-43-0330 (3), (4) and (5).(a) Scope and applicability of this sub-section:

(i) Applies to filings for Grandfathered association health plans.(b) If you request some rate filing information to be proprietary per RCW

48.02.120(3):(i) You must provide one public rate filing and one not-for-public rate

filing.(ii) State clearly in SERFF Product Name Field under General








(c) Rate filing submission requirements(i) On the General Information tab in SERFF

1. Start the SERFF Product name with “Grandfathered Association or Member-Governed Group Closed Pool Rate Filing–[Name of the Association]”

(ii) On the Rate/Rule Schedule tab in SERFF, 1. Include a public rate schedule. [WAC 284-43-0330(3)(a)]

1.1 Must file a large group rate filing which includes rates and rate filing information only for the closed pool enrollees. [WAC 284-43-0330(3)(a)]

(iii) On The Supporting Documentation tab in SERFF1. Provide a certification on the Supporting Documentation tab in

SERFF as described in WAC 284-43-0330(3)(b).1.1 For each grandfathered plan issued to an association or

member-governed group, at a minimum, the items stated in WAC 284-43-0330(4) must be provided.

VII.B. Association or member-governed group to whom the health plan is issued constitutes a true employer under 29 U.S.C. § 1002(5) of the Employee Retirement Income Security Act (ERISA) of 1974 under WAC 284-43-0330(1), and (2).(a) General Information

(i) Must be a small group plan under Section I if the number of participants is fifty or less. [WAC 284-43-0330(1)]

(ii) If the number of participants is more than fifty, must file a single large group rate filing which includes rates and rate filing information only for this group. [WAC 284-43-0330(2)]

(iii) You must submit a separate public rate filing for all new or renewing association groups and for revisions of previous association rate filings; the rate filing must be complete and include a rate schedule.

(b) For information about Speed to Market Tools for see the file named “SMT – Rates – Health Dental Vision – Large Group.”


(c) If you request some rate filing information to be proprietary per RCW 48.02.120(3):










(d) Rate filing submission requirements(i) On the General Information tab in SERFF

1. Start the SERFF Product name with “Association or member-governed true employer group under 29 U.S.C. Section 1002(5) of ERISA–[Name of the Association]”.

(ii) On the Rate/Rule Schedule tab in SERFF1. Provide the rate schedule and group information per WAC 284-

43-6560 and WAC 284-43-6580.(iii) On the Supporting Documentation tab in SERFF

1. Submit filing summary under WAC 284-43-6540 with the experience only for this large group.1.1 For an Excel version of the WAC 284-43-6540 form see the


VII.C. Pathway 2 Association Health Plans (Placeholder)

VII.D.Dental Only or Vision Only Plans for Association or Member-Governed Groups(a) Scope and applicability of this sub-section:

(i) Applies to filings for: 1. Large group association dental only plans, and2. Large group association vision only plans.

(b) For information about Speed to Market Tools for see the file named “SMT – Rates – Health Dental Vision – Large Group.”


(c) If you request some rate filing information to be proprietary per RCW 48.02.120(3):










(d) Rate filing submission requirements(i) Under the General Information Tab in SERFF

1. In the SERFF Product Name field, use “Association [[Dental Only] or [Vision Only]] Rate Filing – [Group Name] – [[for-public] or [not-for-public]]”

1.1.1Choose to include “Dental Only” or “Vision Only” but not both in the above naming convention.

1.1.2Replace [Group Name] in the above naming convention with the actual group’s name.

1.1.3Choose to include “for-public” or “not-for-public” but not both in the above naming convention.

2. In the Submission Type field, indicate the type of submission.3. In the Corresponding Filing Tracking Number field, indicate all

applicable SERFF Tracking IDs for the corresponding rate and form filings.

(ii) Under the Rate/Rule Schedule tab in SERFF:1. Attach applicable group information and rate schedules. [WAC

284-43-6520(11), WAC 284-43-6580]1.1 See the speed to market tools referenced at the beginning of

this section for helpful guidance, recommended template, and illustrative examples related to this filing methodology.

2. List the rate action as “revised” for all renewal filings and “new” for all filings with no rate history.

(iii) Under the Supporting Documents1. Complete and attach Filing Summary under WAC 284-43-6540.

1.1 Name the file “WAC 284-43-6540.pdf”1.2 For an Excel version of the WAC 284-43-6540 form see the



VIII. Medicare Supplement InstructionsVIII.A. General Information

(a) Scope of Section by Type of Insurance (TOI) in SERFF: MS02G, MS02I, MS04G, MS04I, MS05G, MS05I, MS07G, MS07I, MS08G, MS08I



(b) For information regarding Speed to Market Tools see the file named “SMT – Rates – Medicare Supplement Guidance” (Insert link).

(c) Reports such as Refund Calculations, Multiple Policy Reports and Grievance Reports are not being accepted through SERFF. Please see the instructions for submitting these reports at https://www.insurance.wa.gov/instructions-filing-medicare-supplement-annual-reports

VIII.B. Submission requirements:(a) If you are submitting rates for more than one plan on a single filing

you must use the multi-plan codes from the NAIC’s Product Coding Matrix

(b) If both a rate filing and form filing are required:(i) The applicable filings must be submitted concurrently.(ii) The Corresponding Filing Tracking Number field must include the

appropriate tracking numbers for each filing.(c) Under the Rate/Rule Schedule tab:

(i) Fill out the Company Rate Information unless the filing is for new plans. The data provided in the Company Rate Information should only be for Washington experience and for the TOI and company name submitted.

(ii) Include the rate sheet only.(d) Under the Supporting Documentation tab:

(i) Include all supporting documentation and justification. (e) If you request a separate “not-for-public” rate filing per RCW

48.02.120(3),(i) You must provide at least one public rate filing and one not-for-

public rate filing. (ii) State clearly in SERFF Product Name Field under General






IX.Long-term Care Instructions


https://www.insurance.wa.gov/instructions-filing-medicare-supplement-annual-reports



IX.A.1. General Information(a) Scope of Section by Type of Insurance (TOI) in SERFF: LTC02G,

LTC02I, LTC03G, LTC03I, LTC04G, LTC04I, LTC05G, LTC05I, LTC051I, LTC052G, LTC052I, or LTC06

(b) For information regarding Speed to Market Tools see the file named “SMT – Rates – Long Term Care Guidance” (Insert link).

IX.A.2. Submission requirements:(a) Long Term Care Reports Required By WAC 284-83-090

(i) The product name in SERFF must include the words “Experience Report Only.”

(ii) The updated experience report should be filed as a rate filing under the same TOI as the most recent rate manual filing. All documents should be submitted on the Supporting Documentation tab in SERFF.

(iii) Submit your actuarial memorandum and the information required by WAC 284-83-090 (c)(i) on the Supporting Documentation tab.

X. Short-Term Limited Duration Medical Plan Instructions

X.A. General Information(a) Scope of Section by Type of Insurance (TOI) in SERFF: H15I.004 and

H15G.004.(b) For definition of Short-term limited duration medical plan see WAC

284-43-8000(1).(c) Rates, or modification of rates, for short-term limited duration

medical plans must not be used until filed with and approved in writing by the commissioner. [WAC 284-43-8020(2)]

X.B. Submission Requirements:(a) Under the General Information tab in SERFF

(i) In the SERFF Product Name field, the product name must start with “Short-term limited duration medical plan.”

(ii) In the Corresponding Filing Tracking Number field, list all the SERFF Tracking Numbers of the corresponding form filings.

(b) Under the Rate/Rule Schedule tab in SERFF:(i) New or Revised field:

1. If you offered plans in the previous plan year, select “Revised.”2. Otherwise, select “New.”

(ii) Include a complete rate schedule. [WAC 284-43-8020(2)]1. If you choose to include both an Excel file format and PDF

format, include the word “duplicate” in Excel file name.(iii) All other supporting documentation and information should be

attached under the Supporting Documentation tab. (iv) List the affected form number for each plan.



Form Filing InstructionsXI.General Disability Form FilingsXI.A. Scope of Section by Type of Insurance (TOI) in SERFF: H05, H06,

H07G, H07I, H08G, H08I, H09G, H14G, H15G, H17G, H18G, H18I, H19I, H19G, H23G, or H23I

XI.B. Form filing submission requirements:

XI.B.1. If both a rate filing and form filing are required:(a) All of the applicable filings must be submitted concurrently.(b) The Corresponding Filing Tracking Number field must include the

appropriate tracking numbers for each filing.

XI.B.2. If only a form filing is required you must state the reason you are not providing a corresponding rate filing in the filing description.

XI.B.3. Under RCW 48.18.100, all forms that are part of the insurance contract must be filed. This includes the application, policy forms and jackets, endorsements, and specifications pages (completed in John Doe fashion). You may attach supporting documentation (side by side or markup) for a specific form under the Supporting Documentation tab.

XI.B.4. Except for Credit Life and Credit Accident and Health Insurance, you do not have to file notices to policyholders unless they amend policy provisions.

XI.B.5. You must list all filed forms on the Form Schedule tab, and enter form numbers correctly.

XI.B.6. Each form must have a unique identifying number and a way to distinguish it from new forms.

XI.B.7. Disability forms must be in not less than 10-point type.

XI.B.8. Single Case Filing submissions. For each unique group master application and/or group enrollment form filed for review you must file a completed and signed “Custom Enrollment/Application Certification” on the Supporting Documentation tab. The custom applications and enrollment forms filed for review must be attached, in final form, on the Form Schedule tab. You must complete the Form Name field using the following naming convention: “Custom App/Enr [ABC Company].” “ABC Company” means the specific group, trust, association, etc.

XI.B.9. Out-of-State Groups [WAC 284.30.600].


http://apps.leg.wa.gov/rcw/default.aspx?cite=48.20.012




(a) Must file as a new submission. You may not request to re-open a previously approved form or rate filing to modify its contents or to have it apply to new groups.

(b) Must file for approval all certificates providing coverage in the state of Washington. A complete submission includes: applications, riders, or endorsements for approval on the Form Schedule tab.(i) If previously approved applications, riders, or endorsements are to

be used with the new certificate, they must be attached to the Supporting Documents tab and be described in the filing description or cover letter.

(ii) Single case format means group specific language with no bracketing or variability. Bracketing or variability may be used relative to amounts of coverage such as the death benefit and or coverage provisions, such as AD & D on a group life policy where the AD & D is either included or not included based upon the requirements of the policyholder.

(iii) Single case submissions must indicate in the “Group Market Type” field whether it is an Association or Trust.

(iv) Single case format does not apply to employer groups as defined in RCW 48.24.020 or Union Groups as defined in RCW 48.24.050. For an “Employer Group” and or “Union Group” to be exempted from the single case filing requirements, “Employer Group” and or “Union Group” and only these terms can be specified in the “Group Market Type” field.

(c) Trust or Association submissions must file copies of the original, executed trust documents or articles of incorporation and include revised, amended or restated documents on the Supporting Documentation tab.

(d) Must file disclosure statement for approval on the Form Schedule tab [WAC 284.30.610] when Producer solicitation is allowed.

(e) Must disclose in the Filing Description field this is an Out-Of-State Group Filing and follow the prescribed Product Name convention in the Submission Requirements. Groups would use: Out of State Group [ABC Company]; Association or Trusts would use: Out of State [ABC Association]. “ABC Company” means the specific group, trust, association, etc.

XI.B.10. Association, Trust, or Employer Groups domiciled in Washington State(a) Must file for approval the policy, association and trust certificates in

single case format (does not apply to Employer Groups or Union Groups), applications, riders, or endorsements on the Form Schedule tab.(i) If previously approved applications, riders, or endorsements are to

be used with the new policy or certificate, they must be attached to the supporting documents tab and be described in the filing description or cover letter



(ii) Single case format means group specific language with no bracketing or variability (does not apply to Employer Groups or Union Groups).

(iii) Indicate in the “Group Market Type” field whether it is an Association or Trust.

(b) Must file copies of the original trust documents or articles of incorporation and include revised, amended or restated documents on the Supporting Documentation tab [does not apply to Employer Groups or Union Groups].(i) If the group is an association, a copy of the initial association

bylaws must be provided on the Supporting Documentation tab.1. Must include a copy of the Industry Classifications comprising

the eligible groups in the association; or2. An advisory opinion from the Federal Department of Labor

demonstrating the group is qualified to purchase association coverage.

(c) Must disclose in the Filing Description field this is an In-State Group Filing and follow the prescribed Product Name convention in the Submission Requirements. Groups would use: In State Group [ABC Company]; Association or Trust would use: In State [ABC Association]. “ABC Company” means the specific group, trust, association, etc.

XI.B.11. Discretionary Groups under RCW 48.21.010(2) for Accident Only, Disability Income or CHAMPVA and Discretionary Groups under RCW 48.24.027(1) for group life and group annuities. (a) Must file a new submission form filing with a concurrent new rate

filing for each discretionary group, regardless of whether the group is an out-of-state group or not. Previously approved form or rate filings cannot be re-opened to modify contents.

XI.B.12. Must file in compliance with the provisions under RCW 48.21.010 (2) (a) and (b) or RCW 48.24.027(1), (2) and (3) and all applicable filing instructions of rate and form filings.(a) The product name in SERFF must use the following naming

convention: “Discretionary Group - [Group Name].”(b) Must disclose in the Filing Description field that you are filing for a

discretionary group under the requirements of RCW 48.21.010(2) or RCW 48.24.027(1).

XI.B.13. Small Business Retirement System filings (ESSB 5826) for consideration under this program, the filing must contain:(a) A life insurance or annuity form that complies with chapter 48 RCW

and chapter 284 WAC.(b) A certification, submitted as supporting documentation, from an

executive officer as defined in WAC 284.18.340(2) that the form:



(i) Is intended for the Washington small business retirement marketplace.

(ii) Will not charge enrollees more than 100 basis points in total annual fees.

(iii) Will not charge the participating employer an administrative fee.(iv) Will allow enrollees to roll pretax contributions into a different

individual retirement account or another eligible retirement plan after the enrollees cease participation in the retirement plan offered on the Washington small business retirement marketplace.

(v) Is designed for retirement purposes and receives favorable federal tax treatment pursuant to the Internal Revenue Code.

XI.B.14. Life Insurance and Charitable Gift Annuity Forms(a) Life Settlement filings must be submitted on Type of Insurance (TOI)

code LS01(b) Charitable Gift Annuity contract filings must be submitted on Type

of Insurance (TOI) code A10. Filers must attach filed contracts and application forms to the Form Schedule tab. You must attach all other documents (such as cover letters, explanatory memorandums, side-by-sides or marked-up forms) to the Supporting Documentation tab. You must submit a completed compliance checklist under the Supporting Documentation tab for each new contract. See WAC 284.38.030(5).

(c) Life Illustrations Information Filings(i) Life illustration information is no longer accepted via email and

must be submitted through SERFF. Life illustration information is not considered received until successfully submitted through SERFF.

(ii) For information regarding Speed to Market Tools for Life Illustrations see the document named “SMT – Life Illustrations.”1. SMT documents provide detailed guidance about these filings.2. This and related documents are provided on the OIC’s website.

(iii) Submission requirements:1. Use the “Form” filing type in SERFF and TOI: L08.000 “Life-

Other.”2. The insurer shall identify in writing those forms and whether or

not an illustration will be used with them. For policy forms filed after January 1, 1998, the identification shall be made at the time of filing. Any previous identification may be changed by notice to the commissioner. [RCW 48.23A.020(1)]

3. Companies not illustrating any policy forms in Washington State [RCW 48.23A.020(1) and RCW 48.23A.080(4)]



3.1The illustration actuary shall file a certification with the board of directors and with the commissioner…Before a new policy form is illustrated. [RCW 48.23A.080(4)(a)]. See section VII.D.3 below for details.

3.2SERFF Filing Details and Specifications3.2.1 On the General Information tab in SERFF:

3.2.1.1 Use the SERFF Product Name naming convention: “Life Illustrations – No Illustrations Used in WA”

3.3On the Supporting docs in SERFF:3.3.1 Submit a letter stating that the company does not

illustrate any forms. [RCW 48.23A.020(1), RCW 48.23A.080(4) and (5)]

4. Companies illustrating some or all policy forms in Washington State [RCW 48.23A.080(4)]4.1The illustration actuary shall file a certification with the board

of directors and with the commissioner: (i) Annually for all policy forms for which illustrations are used; and (ii) Before a new policy form is illustrated. [RCW 48.23A.080(4)]

4.2The annual certifications shall be provided to the commissioner each year by a date determined by the insurer. [RCW 48.23A.080(7)]

4.3If an illustration actuary is unable to certify the scale for any policy form illustration the insurer intends to use, the actuary shall notify the board of directors of the insurer and the commissioner promptly of his or her inability to certify, please contact the OIC Rates & Forms Help Desk promptly (contact information stated below). [RCW 48.23A.080(5)]


4.4.1.1 Use the SERFF Product Name naming convention: “Life Illustrations – Annual Certifications”

4.4.2 On the Supporting Docs tab in SERFF:4.4.2.1 See the speed to market tools referenced

above for more information regarding supporting documentation.

4.4.2.2 Provide a separate filing deadline letter. [RCW 48.23A.080(7)]

4.4.2.3 Provide a separate document that lists all policy forms to which the law applies. [RCW 48.23A.080(4)]

4.4.2.4 Provide a separate document for the Illustration Actuary’s certification [RCW 48.23A.080(4)(a)]



4.4.2.5 If the company’s life illustrations require more than one Certification, state the applicable lines or partitions of business in the actuary’s certification.

4.4.2.6 Provide a separate document for the Responsible Officer’s illustration certification [RCW 48.23A.080(6)]

4.4.2.7 If life illustrations require more than one Certification, state the applicable lines or partitions of business in the officer’s certification.

5. Illustrating a New Form or Changing from not-illustrating to illustrating policy forms [RCW 48.23A.080(4)(a)(ii)]5.1You must file life illustration certifications before a policy

form is illustrated in Washington State. [RCW 48.23A.080(4)(a)(ii)]

5.2For new forms:5.2.1 If the new form is submitted to OIC through SERFF,

identification shall be made at the time of filing. [RCW 48.23A.020(1)]

5.2.2 Otherwise submit the life illustration notification to OIC separately in SERFF using the instructions below. [RCW 48.23A.080(4)(a)(ii)


5.3.1.1 Use the SERFF Product Name naming convention: “Life Illustrations – [[New Form Illustrations] or [Changing Illustrating Status]]”

5.3.1.2 Choose “New Form Illustrations” or “Changing Illustrating Status” in the above naming conventions.

5.3.2 On the Supporting Docs tab in SERFF:5.3.2.1 See the speed to market tools for

information regarding supporting documentation.6. Changing from illustrating to not illustrating policy forms in

Washington State6.1Submit a filing in SERFF to notify us of the change. [RCW

48.23A.020(1)]6.2SERFF Filing Details and Specifications

6.2.1 On the General Information tab in SERFF:6.2.2 Use the SERFF Product Name naming convention:

“Life Illustrations – Annual Certifications – Not illustrating in WA”

6.3On the Supporting Docs tab in SERFF:



6.3.1 Submit a letter that states the company is not illustrating any policy forms and include an effective date for the change. [RCW 48.23A.020(1), RCW 48.23A.080(4) and (5)]

7. New or changing illustration actuary7.1If an insurer changes the illustration actuary responsible for

all or a portion of the company's policy forms, the insurer shall notify the commissioner of that fact promptly per instructions below. [RCW 48.23A.080(8)]


7.2.1.1 Use the following SERFF Product Name naming convention: “Life Illustrations – Illustration Actuary Change”

7.2.2 On the Supporting docs in SERFF:7.2.2.1 Submit documentation regarding the new

Illustration Actuary’s appointment by the board and the effective date. [RCW 48.23A.080(1)

7.2.2.2 Submit a letter that states the reason for the change. [RCW 48.23A.080(8)]

XII. Long Term Care FormsXII.A. Long Term Care advertising must be submitted on an LTC06-Other TOI code.

XII.B. Requirements for Long-term Care Partnership Filings(a) You must file your LTC partnership forms under the proper LTC

Partnership Sub-TOI code. Please refer to the NAIC’s Product Coding Matrix for the proper code.

(b) If a partnership certification form is to apply to multiple partnership Sub-TOIs, then a separate Partnership Certification form must be filed under the Form Schedule tab for each Sub-TOI. If the Partnership Certification form will be used with an Interstate Compact approved policy form, you must submit a copy of the Compact approved policy under the Supporting Documentation tab.

(c) A long-term care partnership policy certification form must be completed for each policy or certificate, and submitted under the Form Schedule Tab. In addition, filers must submit the partnership status disclosure notice and the partnership program notice which will be used with the policy or certificate. These should be submitted under the Form Schedule Tab and should include the word ‘Partnership’ in the Form Name field.

(d) You must indicate in the Filing Description and the Product Name field this is a LTC Partnership filing.



XIII. Medicare Supplement FormsXIII.A. Scope of Section by Type of Insurance (TOI) in SERFF: MS02G, MS02I,

MS04G, MS04I, MS05G, MS05I, MS07G, MS07I, MS08G, MS08I

XIII.B. Reports such as Refund Calculations, Multiple Policy Reports and Grievance Reports are not being accepted through SERFF. Please see the instructions for submitting these reports at https://www.insurance.wa.gov/instructions-filing-medicare-supplement-annual-reports.

XIII.C. Submission Requirements:(a) If you are submitting more than one plan on a single filing you must

use the multi-plan codes from the NAIC’s Product Coding Matrix(b) Notice of plan closures must be filed as a unique form filing. The

document must include a form number in the lower left hand corner and be filed on the Form Schedule tab.

(c) Medicare supplement advertising must be submitted on an MS06 or MS09 TOI code

XIV. Your filing is incomplete and will be rejected if:

(a) We cannot download your filing into our back office system. There are a number of reasons why we cannot download filings into our back office system. The most common reasons include:

(b) Attachments are not formatted using a Distiller in PDF format.(c) An incorrect CoCode number is entered in the Filing Company

Information, under the Companies and Contact tab. This CoCode number is the same number as your company's 5-digit NAIC number.

(d) Health Care Service Contractors and Health Maintenance Organizations do not populate the company tracking number field.

(e) You include an incorrect or incomplete Type of Insurance (TOI) or Sub-TOI as listed on the NAIC Uniform Life, Accident & Health, Annuity and Credit Product Coding Matrix.

(f) Documents in the filing are not machine readable.

XV. Rejected Filings will not be Re-Opened(a) If the OIC Technical Support Unit rejects your filing, you must

submit a new filing following the procedures in our Rejection Notice and General Instructions.





XVI. SERFF Objection Letter Response Requirements for Rate Filings

(a) Unless instructed otherwise, all attachments to responses must be in PDF format.

(b) When responding to an objection letter, you must use SERFF’s Amend Filing function.

(c) You must answer each objection individually. (d) Never use a General Update to change a filing after it has been

reviewed by an OIC analyst.(e) Rates accepted for review generally cannot be changed, other than

changes required to be made in response to objections.

XVII. To request to make a change to a rate filing after it has been accepted for review; Direction for permission to amend filings under WAC 284-43-0200

(a) You must send a Note to Reviewer requesting to replace, modify, add, or withdraw the rate filing after it has been accepted for review. The Note to Reviewer must be sent in the filing you are requesting to change.

(b) Your analyst will notify you in a Note to Filer whether your request is accepted or denied.

(c) If your request is denied, you may not modify the filing. You may request the filing be withdrawn.

(d) If your request is accepted, you may update your filing as directed in the Note to Filer.

(e) Do not use “Note to Reviewer” to submit an objection response.(f) Responses should be submitted in a timely manner.

XVIII. After a Final Disposition by OIC Analyst(a) After final disposition by an OIC Analyst you may not change or

correct the filing. You must make a new filing in SERFF.

XIX. Contact UsFor filing related questions, contact the Rates & Forms Help Desk:

(360) [email protected]

For feedback or suggestions, email us:OIC Feedback mailbox address


mailto:[email protected]