As required under the law, and in furtherance of its mission to protect consumers, the DMHC reviews the health plans’ financial and compliance information on an ongoing basis to ensure a financially stable health care delivery system.
The DMHC provides the tools health plans need to submit all of the appropriate financial and compliance filings and reports.
Submit Financial Reporting Forms
All health plans are required to report their periodic financial information using the DMHC Financial Reporting Forms. Please login to the DMHC’s web portal for the DMHC Financial Reporting Form templates and reporting instructions. Please submit the completed DMHC Financial Reporting Form through the DMHC web’s portal.
Health Plan Web Portal
If you need access to the DMHC’s web portal, please see your Administrator Account user. If you do not know who the Administrator Account user is, please contact the Office of Plan Licensing at 916-324-9046.
If you have any further questions please contact healthplanreporting@dmhc.ca.gov or call 916-255-2345.
Annual Dental Medical Loss Ratio (MLR)
Use the Dental MLR Reporting Form below for annual dental MLR reporting.
Dental Medical Loss Ratio Reporting Form
Dental Medical Loss Ratio Reporting Instructions
Dental Medical Loss Ratio Guidance
If you need access to the DMHC’s web portal, please see your Administrator Account user. If you do not know who the Administrator Account user is, please contact the Office of Plan Licensing at 916-324-9046.
Please provide comments and feedback at healthplanreporting@dmhc.ca.gov regarding the reporting forms.
Financial Solvency Reports
Health plans are required to provide the DMHC with certain information relating to the risk assigned to their provider network on a quarterly and annual basis.
Submit Financial Solvency Reports
View List of Capitated Providers and RBOs
Claims Settlement Practices and Dispute Resolution
The Quarterly and Annual Claims Settlement Practices Reports are required to be submitted for each licensed health plan. Health plans report claim information if the plan or any of its capitated providers have failed to timely reimburse at least 95% of complete claims with correct payment including interest and penalties due, that became payable during the reporting period.
Submit Claims Settlement Practices and Dispute Resolution
Click the link below to view the summary of the Quarterly Claims Settlement Practices Report:
Quarterly Claims Settlement Practices Report Summary
Rate Filing (Premium Rate Review and Aggregate Rate Data)
The DMHC issued the following letters to provide guidance to health plans regarding premium rate filings:
Director’s Letter (Letter 8-K) was issued on September 2, 2016 and amends May 24, 2011 and February 2, 2012 versions. This letter provides additional guidance to health plans regarding individual and small group premium rate filings and aggregate data submissions. This letter also provides guidance for large group aggregate rate information submissions discussed below.
Director’s Letter (Letter 11-K) was issued on July 2, 2012, to provide additional guidance to health plans regarding premium rate filings for individual policies sold through associations.
Rate Review for Individual and Small Group Markets
Beginning January 1, 2011, health plans are required to submit rate filings to the DMHC pursuant to Senate Bill 1163 (Leno, Chapter 661, Statutes of 2010). All rate filing documents are to be submitted through the National Association of Insurance Commissioners’ System for Electronic Rate and Form Filing (SERFF).
In addition, Assembly Bill 731 (Kalra, Chapter 807, Statutes of 2019) amended Health and Safety Code section 1385.01 and amended, repealed, and added section 1385.03 to require health plans to include annual medical trends by geographic rating region trends in the individual and small group rate filings.
The DMHC has released the following guidance and the Individual and Small Group Workbook for submissions via the SERFF system:
Individual and Small Group Guidance
Individual and Small Group Workbook
Further guidance regarding rate filing and rate filing contents may be released later.
Aggregate Rate for Individual and Small Group Markets
Assembly Bill 2118 (Kalra, Chapter 277, Statutes of 2020) requires health plans to annually report specified rate information on premiums, cost sharing, benefits, enrollment, and trend factors for products in the individual and small group markets for all grandfathered and non-grandfathered products. All aggregate rate filing documents are to be submitted through the National Association of Insurance Commissioners’ System for Electronic Rate and Form Filing (SERFF). The individual and small group annual aggregate rate information submitted by health plans is posted under Premium Rate Review. The DMHC is required to present the information annually.
The DMHC has release the following guidance and the Individual Annual Aggregate Rate Workbook and Small Group Annual Aggregate Rate Workbook via the SERFF system.
Individual and Small Group Annual Aggregate Rate Guidance
Individual Annual Aggregate Rate Workbook
Small Group Annual Aggregate Rate Workbook
Rate Review for Large Group Market
Assembly Bill 731 (Kalra, Chapter 807, Statutes of 2019) amended, repealed, and added section 1385.03 of the California Health and Safety Code. This bill requires health plans offering a large group health care service plan contract to file information regarding the methodology, factors, and assumptions used to determine rates with the Department of Managed Health Care (DMHC) at least annually and 120 days before implementing any change in the methodology, factors, or assumptions that would affect the rates paid by a large group. All rate filing documents are to be submitted through the National Association of Insurance Commissioners' System for Electronic Rate and Form Filing (SERFF).
The DMHC has release the following guidance and the Large Group Workbook for submissions via the SERFF system:
Large Group Guidance
Large Group Workbook
Aggregate Rate and Prescription Drug Cost Data for Large Group Market
Beginning October 1, 2016, health plans are required to submit aggregate rate information to the DMHC pursuant to Senate Bill 546 (Leno, Chapter 801, Statutes of 2015). In addition, beginning October 1, 2018, health plans are required to submit specific prescription drug cost information to the DMHC pursuant to Senate Bill 17 (Hernandez, Chapter 603, Statutes of 2017). All rate filing documents are to be submitted through the National Association of Insurance Commissioners’ System for Electronic Rate and Form Filing (SERFF). The large group aggregate rate information submitted by health plans is posted under Premium Rate Review.
Additionally, the DMHC is required to hold a public meeting every even-numbered year to discuss the large group aggregate rate and prescription drug cost information submitted to the DMHC and to provide an opportunity for public discussion of the reasons for the changes in the rates, benefits, and cost sharing in the large group market.
The DMHC has released the following guidance and the Large Group Aggregate Rate and Prescription Drug Cost Data Workbook for submission via the SERFF system:
Large Group Aggregate Rate and Prescription Drug Cost Data Guidance
Large Group Aggregate Rate and Prescription Drug Cost Data Workbook
Prescription Drug Cost Data for Commercial Plans
Beginning October 1, 2018, health plans are required to submit prescription drug cost information to the DMHC pursuant to Senate Bill 17 (Hernandez, Chapter 603, Statutes of 2017). All cost filing documents for commercial plans are to be submitted via the DMHC e-filing portal.
Additionally, the DMHC is required to aggregate the data that it receives from health plans and compile a report for the public and legislators that demonstrates the overall impact of prescription drug costs on health care premiums. Information specific to individual health plans is considered confidential and will be withheld from public disclosure.
The DMHC has released the following forms for submissions via the DMHC's e-filing portal:
SB 17 - Prescription Drug Cost Reporting Form for Commercial Plans
Instructions for SB 17 - Prescription Drug Cost Reporting Form for Commercial Plans
For large group health care service plan contracts, SB 17 requires specific cost information regarding covered prescription drugs be filed through SERFF. The DMHC has created reporting forms and instructions for this submission that can be found in the above section, Rate and Prescription Drug Cost Data for Large Group Market.
Further guidance regarding rate filing and rate filing contents may be released later.
Large Group Contractholder Rate Review Request
Beginning July 1, 2021, upon receiving notice of a rate change, a large group contractholder that has coverage that is experience rated in whole or blended can request the DMHC to review a rate change, if the contractholder makes the request within 60 days of receipt of their notice. A large group contractholder may only request a review of a rate change from a health plan licensed by the DMHC. To apply for a review of a rate change for a particular group at least one of the following should apply:
- The contractholder has a combined total of more than 2,000 enrollees (employees plus dependents) enrolled in all health plans.
- The rate change is from a health plan that failed to provide you with information required under Article 6.2 of the KKA (Review of Rate Increases) or Section 1385.10 of the Health and Safety Code (Health Plan Annual Claims Reporting Requirements). See the California Health and Safety Code section 1385.10.
Request the DMHC to review a rate change