Actuarial Soundness. Insurer shall provide an actuarial memorandum supporting the premium rate adjustment request. The actuarial memorandum shall include the information and level of detail required by FHKC. The proposed premium rates shall:
a. Be consistent with actuarially sound principles as required by 42 CFR 457.1203;
b. Not be excessive nor inadequate in accordance with the applicable requirements of Chapter 409, Florida Statutes; and
c. Be designed to reasonably achieve a medical loss ratio (MLR) standard for the Contract year that is at least equal to the greater of eighty-five percent (85%) or as presented in response to the ITN and provide for reasonable administrative costs in accordance with 42 CFR 457.1203 and section 9.5 of this Contract.
Actuarial Soundness. Insurer shall provide an actuarial memorandum supporting the premium rate adjustment request. The actuarial memorandum shall include the information and level of detail required by FHKC. The proposed premium rates shall:
a. Be consistent with actuarially sound principles as required by 42 CFR 457.1203;
b. Not be excessive nor inadequate in accordance with the applicable requirements of Chapter 409, Florida Statutes; and
c. Be designed to reasonably achieve a medical loss ratio (MLR) standard for the Contract year that is at least equal to the greater of eighty-five percent (85%) or the target MLR implicit in Insurer’s best and final offer in response to the ITN and provide for reasonable administrative costs in accordance with 42 CFR 457.1203, Section 624.91, Florida Statutes, and section 9-5 of this Contract.
Actuarial Soundness. In determining Capitation Rates for all Cohorts, as described in this Article, the State shall calculate Actuarially-Sound Capitation Rates in accordance with all federal laws and regulations for which the CONTRACTOR provides the CLTS benefits package. The State shall make payments under capitated risk contracts, which are actuarially sound. Capitation Rates shall be developed in accordance with generally accepted actuarial principles and practices. Capitation Rates must be appropriate for the populations to be covered, the Covered Services to be furnished under this Agreement and be certified as meeting the foregoing requirements by actuaries. The actuaries must meet the qualification standards established by the American Academy of Actuaries and follow the practice standards established by the Actuarial Standards Board. Accordingly, the State’s offer of all Capitation Rates referred to in the attached schedule of this Agreement is contingent on both certification by the State’s actuary for actuarial soundness and final approval by CMS, prior to becoming effective for payment purposes. In the event such certification of approval is not obtained for any of all Capitation Rates, the State reserves the right to renegotiate or set these rates. The State’s decision to renegotiate or set the rates under this provision is binding on the CONTRACTOR.
