2015 Federated Small Group Rate Filing PDF

ActuarialMemorandum
RateFilingforFederatedMutualInsuranceCompany
StateofMissouri
SmallGroupPolicyForm#:GH2410(0114ed.)
1.GeneralInformation
CompanyIdentifyingInformation
CompanyLegalName:FederatedMutualInsuranceCompany
State:Missouri
HIOSIssuerID:64701
Market:SmallGroup
EffectiveDate:January1,2015
CompanyContactInformation
PrimaryContactName:JaniceKautz
PrimaryContactTelephoneNumber:8005330472ext.5129
PrimaryContactEmail:jbkautz@fedins.com
Market
SmallGroupMarket
DescriptionofBenefits
TheformlistedaboveisaPreferredProviderOrganization(PPO)healthinsuranceproductmarketedto
smallemployers(1to50employees).Benefitsarecomprehensiveinnature,andincludeprescription
drugs.Acompletelistingoftheplanoptionsfordeductible,coinsurance,outofpocketmaximumand
copaymentisshowninAttachmentAofthismemorandum.
MarketingMethod
Federatedmarketsthroughitsowndirectsalesforce,whichfocusesonsmallercompaniesinselecttypes
ofbusiness.
2.ProposedRateChange
ReasonforRateChange
ThepurposeofthismemorandumistofileratesandbenefitplansincompliancewiththePatient
ProtectionandAffordableCareAct(PPACA)andtoproposearateincreaseforFederatedMutual
InsuranceCompany's(Federated)PolicyFormGH2410(0114ed.).Theratesinthisfilingwillapplyto
newandrenewalbusinessontheaboveformonorafterJanuary1,2015.Federatedisalsoproposing
annualtrendadjustmentsof4.00%.
FortheStateofMissouri,theproposedratesareanincreaseof6.1%fromcurrentratelevels.Therate
changeisdrivenbyclaimcostexperience,projectedtrend,assumeddiscountlevelsandtheimpactof
ACARiskAdjustment.Theratechangewillvarybyratingareaandplan.
Basedonastudyperformedforusbyanexternalconsultant,theproposedratechangeincludesan
assumedcostof7.0%duetoRiskAdjustment.Basedon2015experience,weareassumingapayment
intotheRiskAdjustmentprogram.
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3.ExperiencePeriodPremiumandClaims
PaidThroughDate
Theclaimsincludedintheexperienceperiod,January1,2013throughDecember31,2013,includeall
claimsincurredintheStateofMissouriduringtheexperienceperiodandpaidthroughMarch31,2014
plusanestimateofincurredbutnotpaidclaims.
Premiums(netofMLRRebate)inExperiencePeriod
Premiumsintheexperienceperiodwereobtainedatagrouplevelfromaninternaldatasystem.Since
noMLRrebateswerepaidinMissouriduringtheexperienceperiod,earnedpremiumbeforeandnetof
MLRadjustmentsis$23,965,909.
AllowedandIncurredClaimsIncurredDuringtheExperiencePeriod
Claimswereobtainedfromclaimrecordsstoredinaninternaldatasystem.Allmedicalclaimsare
processedthroughFederatedsystems.Pharmacyclaimsareprocessedoutsidethesystembya
PharmacyBenefitManager(PBM).
Claimsthathavebeenincurredbutnotreportedareestimatedusingacompletionfactorapproach
basedonFederatedsentireblockofgroupmedicalbusiness.Thisapproachusestraditionalactuarial
practicestoaccountforhistoriccompletionpatternsandunusual(onetime)events.Reservesforthe
experienceperiodwereneitherunusuallyhighnorunusuallylow.
Federatedsblockofgroupmedicalbusinessconsistsofsimilarproductsofferedintwentythreestates.
Ratesontheseproductshavebeencalculatedtobeactuariallyequivalentandexperiencefromthese
productshasalwaysbeencombinedforreservingpurposes.Thecompletionpatternoftheblockof
businessisassumedtobeconsistentwiththeproductsincludedintheexperienceforthisfiling.
Duetothesmallamountofexperienceincludedinthisfiling,completionfactorsareappliedtothe
blockclaimstoestimateablockreserveswhichisthenallocatedtoportionsofthebusiness.
Paidandallowedclaimreservesareallocatedbasedonearnedpremium.
4.BenefitCategories
ThebenefitcategoriesforURRTWorksheet1wereassignedtoclaimsbasedonthefollowingmethodology:
InpatientHospital
Facilityandaccommodationchargesthatappearonan837IorUBwithanaccommodationcharge.
OutpatientHospital
Facilitychargesthatappearonan837IorUBwithoutanaccommodationcharge.
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OtherMedical
Chargessubmittedonand837PorHCFAbillforAmbulanceServices,Dental,Durablemedical
Equipment,HomeHealthCare,MedicalSupplies,ProstheticsorOrthotics.
Professional
Providerchargesthatappearon837PorHCFAthatarenotincludedforservicescoveredunderOther
Medical.
PrescriptionDrug
ChargesprocessedbyaPBMforprescriptiondrugsdispensedbynetworkpharmaciesandchargesfor
prescriptiondrugsdispensedinaprofessional,inpatientoroutpatientsettingwithlineitembilling.
Capitation
Therewerenocapitationagreementsinplaceduringtheexperienceperiod.Nocapitationagreements
areanticipatedfortheprojectedperiod.
Forchargesthatarecombinedintoasinglefee,eitherbasedontheproviderbillingornetworkrate
negotiationsthechargesareunabletobesplitintofacilityandprofessionalcomponents.Inthesecasesall
chargesareassignedtothefacilitycategory,InpatientHospitalorOutpatientHospital.
5.ProjectionFactors
ChangesintheMorbidityofthePopulationInsured
Thelossofunderwritingcombinedwithguaranteedissuerequirementsareexpectedtoincreasethe
averagepermemberclaimcostwithinthesmallgroupmarket.Federatedexpectsthesechangesto
havesimilareffectsonitssmallgrouppopulationasonthesmallgroupmarketasawhole.
Theincreaseinmorbiditywasestimatedusingunderwritingresultsandactuarialjudgment.Theitems
consideredintheadjustmentwere:lossofunderwritingandthemorbidityimpactduetothe
transitionalreliefoption.
ChangesinBenefits
Additionalbenefitsforhabilitativecare,rehabilitativecareandpediatricvisionduetoEssentialHealth
Benefitrequirementsandthecoverageofbenefitsforpreexistingconditionswillbeprovided.
Federatedinternalanalysis,historicalclaimdenialsandactuarialjudgmentwereusedtoestimatethe
impactofthesebenefits.
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ChangesinDemographics
Adjustmentsweremadetothedataforageanddurationtobringthesingleriskpooldatatothelevelof
ournationwideblock.Asanewproductitisexpectedthattheagemixturewillbesimilartothatofthe
Federatednationwidepopulation.Thefederalagefactorswereusedforthisadjustmentasthosewill
bereflectiveofpremiumdifferenceinthefuture.
OtherAdjustments
AlldataisbasedonallowedchargeswhichreflectprovidercontractingofmultiplePPOnetworks.An
adjustmentwasmadetodatawheretheunderlyingdiscountsbasedonthemixofPPOsinthedatawas
differentfromtheexpecteddiscountsduringtheprojectionperiod.Theadjustmentwasmadeapplying
thedifferencetotheallowedclaimsexperiencebycomparingtherelativecostsofthePPOsinthedata
withtheexpecteddistributionofmembershipandprojectednetworkcostlevels.
Theconsiderationsforthe"OtherAdjustments"included:removalofpreexistingconditionlimits,
additionalbenefitsduetoEHBrequirementscomparedtotheexperienceperiod(nonACAexperience),
changestothePharmacyBenefitsManager,adjustmentsduetochangesinPPOdiscounts,pooling
chargesforthecategoryandtheadditionalcostofoutofnetworkbenefits.
TrendFactors
Federatedcalculatestrendinternally,basedonhistoricalnationwideclaimresults.Separateestimates
aremadeformedicalandpharmacyclaims,withadjustmentsforlargeclaims.
Historicaltrendsarecalculatedbasedonallowedcharges,permemberpermonth.Claimsareadjusted
forseasonalityandforonetimeevents,suchastherenegotiationofapharmacycontract.
Basedontheresultsofthisstudy,Federatedisestimatinganannualcosttrendof4.0%incombined
medicalandpharmacyallowedcosts.Noaggregatetrendisassumedforunderwritingwearofforanti
selection.
Thetrendimpactwillberecognizedonaquarterlybasis.Theeffectofthetrendincreasesontheindex
rateisshownonAttachmentB.
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Thetrend,bycategory,is:
Inpatient:3.0%(weightof22%)
Outpatient:4.0%(weightof32%)
Professional:3.5%(weightof28%)
PBMPharmacy:5.0%(weightof15%)
nonPBMPharmacy:10.0%(weightof1%)
Other:10%(weightof2%)
TotalTrend:4.0%
6.CredibilityManualRateDevelopment
SourceandAppropriatenessofExperienceDataUsed
Federatedcurrentlysellsaproductsimilartotheoneintheexperienceperiodintwentythreestates.
RatesonallofFederatedssmallgrouphealthinsuranceplansarecalculatedtobeactuarially
equivalent.Experienceonallsmallgroupformshasalwaysbeencombinedforratingpurposes.
Federatedassumesthatitsnationwideexperienceiscredible,butthatstatespecificexperiencemay
notbeso.Federatedusedexternalconsultantdatatoassistinestablishingstateandarealevel
adjustmentfactorsinthedevelopmentofmanualrates.
Claimsaredividedintofiveservicecategories:InpatientHospital,OutpatientHospital,Physician
Services,PrescriptionDrugs,andOthercharges.Foreachofthesecategories,AllowedChargesper
member,permonth(PMPM)werecalculatedonbothastatespecificandanationwidebasis,forthe
experienceperiodof1/1/2013through12/31/2013.
AdjustmentsMadetotheData
AlldataisbasedonallowedchargeswhichreflectprovidercontractingofmultiplePPOnetworks.An
adjustmentwasmadetodatawheretheunderlyingdiscountsbasedonthemixofPPOsinthedatawas
differentfromtheexpecteddiscountsduringtheprojectionperiod.Theadjustmentwasmadeapplying
thedifferencetotheallowedclaimsexperiencebycomparingtherelativecostsofthePPOsinthedata
withtheexpecteddistributionofmembershipandprojectednetworkcostlevels.Additionalbenefits
forhabilitativecare,rehabilitativecareandpediatricvisionduetoEssentialHealthBenefit
requirementsandthecoverageofbenefitsforpreexistingconditionswillbeprovided.Theincreasein
morbiditywasestimatedusingunderwritingresultsandactuarialjudgment.
InclusionofCapitationPayments
Federateddoesnotusecapitationpayments.Noneareincludedintheratedevelopment.
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7.CredibilityofExperience
DescriptionofCredibilityMethodologyUsed
Thenationwidecappedchargesareusedtodeterminethemembermonthsneededtodeterminethe
credibilitylevelforeachprimaryservicecategory,ineachstate.Foreachprimaryservicecategory,the
membermonthsneededforfullcredibilityaredeterminedbytheequation:
Variance of Capped Allowed Charges PMPM

1,082 1
Mean of Capped Allowed Charges PMPM 2
ThederivationofwhichcanbefoundinthepaperAnIntroductiontoCredibilityTheorybyL.H.
LongleyCook,whichcanbefoundontheinternetat
http://www.casact.org/pubs/proceed/proceed62/62194.pdf.
Foreachprimarycategory,credibilityiscalculatedas:
State - Specific Member Months during the Experience Period

Member Months Needed for Full Credibilit y
withamaximumcredibilityof1.000.Thedeterminationofcredibilitybyprimaryservicecategoryis
showninAttachmentC.
Foreachprimaryservicecategory,thecappedallowedchargesPMPMarecomparedtoFederateds
nationwideallowedchargesPMPMbyprimaryservicecategory,andcredibilityisapplied(ifnecessary)
byusingthefollowingequation:
Credibilized Allowed Charges PMPM State - Specific Capped Allowed Charges PMPM Credibility Factor
NationwideAllowed Charges PMPM 100% - Credibility Factor
Theresultingvalue(summedforallprimaryservicecategories)iscomparedtotheoriginalcalculation
ofallowedchargespermember,permonth.Theratioofthesetwovaluesisappliedtoactualpaid
claims,asthecredibilityadjustmentinthebaselossratiocalculation.
8.PaidtoAllowedRatio
ThepaidtoallowedratiobyplanisshowninAttachmentF.
9.RiskAdjustmentandReinsurance
ProjectedRiskAdjustmentsPMPM
FortheStateofMissouri,theproposedratesareanincreaseof6.1%fromcurrentratelevels.Therate
changeisdrivenbyclaimcostexperience,projectedtrend,assumeddiscountlevelsandtheimpactof
ACARiskAdjustment.Theratechangewillvarybyratingareaandplan.
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Basedonastudyperformedforusbyanexternalconsultant,theproposedratechangeincludesan
assumedcostof7.0%duetoRiskAdjustment.Basedon2015experience,weareassumingapayment
intotheRiskAdjustmentprogram.
ProjectedACAReinsuranceRecoveriesNetofReinsurancePremium
Reinsurancerecoveriesareexpectedtobe$0astherecoveriesareonlyavailableintheindividual
market.Thereinsurancepremiumof$3.67PMPMisincluded.
10.NonBenefitExpensesandProfit&Risk
AdministrativeExpenseLoad
Administrativeexpenses(notincludingtaxes)areassumedtobe14.7%ofpremiumintheprojection
period.Thepercentageloaddoesnotvarybyproductorplanandisnotallocatedonaperpolicybasis.
Federatedmarketsitsgrouphealthproductsthroughitsowndirectsalesforceanddoesnotuse
independentagentsorbrokers.Salescommissionswere1.2%ofpremium.
Profit(orContributiontoSurplus)&RiskMargin
For2015,FederatedistargetingaContributiontoSurplusof3.0%inMissouri.Noadditionalriskmargin
isincluded.
TaxesandFees
AlltaxesandfeesinMissouritotaled2.3%ofpremium.
For2015,Federatedassumesanadditional1.4%intaxesduetotheadditionaltaxesandfeesimposed
bytheACA.
11.ProjectedLossRatio
Theprojectedlossratio,onaMLRbasis,isshowninAttachmentD.
12.SingleRiskPool
Thesingleriskpoolsmallgroupplanswereestablishedinaccordancewiththerequirementsof45CFRpart
156,156.80(d).Thesingleriskpoolreflectscoveredlivesinallnongrandfatheredproductssoldinthe
StateofMissourismallgroupmarket.ProjectedvaluesreflectexperienceformembersinnonACA
compliantplansduringthehistoricalperiod,totheextenttheyareanticipatedtobeinACAcompliant
plansduringtheprojectionperiod.
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13.IndexRate
Theindexratefortheexperienceperiodistheallowedclaimspermemberpermonthforthesinglerisk
poolconsistingofFederatedssmallgroupbusinessduringthisperiod.Adjustmentsweremadetothis
rate,asdescribedaboveintheProjectionFactorsandtheCredibilityManualRateDevelopmentsections,
tomovetheexperienceperiodratetotheprojectionperiodindexrate.
Theindexrateintheprojectionperiodistheexpectedallowedclaimspermemberpermonthfor
FederatedssingleriskpoolforsmallgrouppoliciesinMissouri.Theclaimshavebeenadjustedfor
quarterlytrendincreasesandtheaverageisweightedontheprojectedmembershipasshownin
AttachmentB.Nofurtheradjustmentstotheexpectedclaimsweremadeforbenefitsasthispolicyformis
coveringnobenefitsinexcessofEHB.
Planratelevelscanbederivedfromtheprojectedindexratebyadjustingforplandesignandcostsharing
characteristics,asshownintheAVPricingsectionbelow,andexpectedexpense.Forindividuals,these
ratesarefurtheradjustedbasedontheindividualsage(usingthefederallyprescribedagecurve),the
geographicarea,andanticipatedprovidernetworkcostdifferences.
14.MarketAdjustedIndexRate
TheMarketAdjustedIndexratewascalculatedastheIndexRateadjustedforallallowablemarketwide
modifiersasdefinedinthemarketratingrules,45CFRPart156,156.80(d)(1).Theadjustmentsmay
include:FederalReinsuranceProgramFeesandRiskAdjusterFees.
15.PlanAdjustedIndexRates
PlanadjustedindexratesreflecttheMarketAdjustedIndexRateadjustedforallowableplanlevel
modifiersdefinedinthemarketratingrules,45CFRPart156,156.80(d)(2).Theseadjustmentsmay
include:planactuarialvalueandcostsharingvaluefactor,benefitsundertheplaninadditiontoEHB,
distributionandadministrativecostsandtheplanprovidernetwork,deliverysystemcharacteristicsand
utilizationmanagementpractices.
16.Calibration
AttachmentGprovidesanillustrationforthedevelopmentoftheapplicablecalibrationfactorsforageand
geographicarea.
17.ConsumerAdjustedPremiumRateDevelopment
AttachmentAprovidesanillustrationforthedevelopmentofconsumeradjustedpremiumratesforsample
insuredmembers.The"IndividualRate"istheConsumerAdjustedPremiumRate.
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18.AVMetalValues
AllAVMetalValuesshowninWorksheet2ofthePart1UnifiedRateReviewTemplatewereentirelybased
ontheAVCalculatordevelopedandmadeavailablebyHHS.
19.AVPricingValues
TheAVPricingValuesforeachProductIDareinWorksheet2,SectionIoftheUnifiedRateReview
Template.ThedevelopmentoftheAVPricingvaluesisshowninAttachmentG.Consistentwithfinal
Marketrules,utilizationadjustmentsaremadetoaccountformemberbehaviorvariationsbasedupon
costsharevariationsofthebenefitdesignandnotthehealthstatusofthemember.Thebehavior
modificationsarebasedontheamountsdevelopedwithintheAVCalculator.
20.MembershipProjections
Membershipprojectionsarebasedon10%ofmembersonnonACAcompliantplansmovingtoACA
compliantplansalongwithadditionalmembershipfromnewsalesduringtheyear.Newsaletargetsare
basedonhistoricalproduction.
Enrollmentbymetaltierisbasedonhistoricaldistribution.Enrollmentbetweentheplanswithinametal
tieraredistributedevenlyforagivennetwork.
21.TerminatedProducts
Noproductswillbeterminated.
22.PlanType
FormGH2410(0114ed.)isaPPOproductasselectedinWorksheet2Section1oftheURRT.Nofurther
descriptionisnecessary.
23.WarningAlerts
None
24.EffectiveRateReviewInformation
Rates
RateFactors,includinggeographicareadefinitionsandcostsharingvariations,areshownin
AttachmentA.
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ProjectedAveragePremium
TheprojectedaveragepremiumfornewPolicyFormGH2410(0114ed.)inMissouriis$293.75per
memberpermonth.Thecurrentaveragepremiumpermemberpermonthontheformis$276.97.
Therearecurrently386membersonthisforminMissourionMay1,2014.
CompanyFinancialCondition
RiskBasedCapital:FederatedMutualisprimarilyaproperty/casualtyinsurancecompany.Health
insuranceisapproximately30%ofpremiums.Overall,FederatedsRBCisapproximately1,871%of
AuthorizedControlLevel.
CompanySurplus:AsofDecember31,2013,FederatedMutualInsuranceCompanyhadsurplusof
$2.53billion.
RateGuarantee
Thepremiumchargedwillnotbeadjustedmorefrequentlythanannuallyexceptthatthepremiumrate
maybechangedtoreflectchangesto(i)familycompositionofthemember;or(ii)coveragerequested
bythemember.
Renewability
Federatedoffersthisproductonaguaranteedrenewablebasis.
RateHistory
Therehavebeennopriorratechangesonthisform.
25.Reliance
TheinformationcontainedinthismemorandumandtheURRTsubmissionwerecreatedwithrelianceon
calculations,assumptions,analysisandotherworkcompletedbytheinternalstaffofFederatedMutual
InsuranceCompany,andassuchwasreliedonbythecertifyingActuary.Forareafactors,statefactorsand
RiskAdjustment,wereliedontheworkperformedbyexternalconsultingfirms.
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26.ActuarialCertification
I,ScottD.Haglund,amamemberoftheAmericanAcademyofActuariesandmeettheQualification
StandardsoftheAcademytorendertheactuarialopinioncontainedherein.Icertify,tothebestofmy
knowledgeandjudgment,:
TheratesproposedinthismemorandumareinfullcompliancewithallapplicableMissouristatutes
andregulationsandtheapplicableFederalstatutesandregulations(45CFR154.215);
TheproposedindexratewasdevelopedincompliancewithallapplicableActuarialStandardsof
Practice;
Theproposedratesarereasonableinrela ontothebenefitsprovidedandthepopula onan cipated
tobecovered;
Thepremiumscheduleisnotexcessive,inadequate,norunfairlydiscriminatory;
Theproposedratesareuniformlyappliedtohealthbenefitplanscoveringsmallemployers;
Theindexrateandonlytheallowablemodifiersasdescribedin45CFR156.80(d)(1)and45CFR
156.80(d)(2)wereusedtogenerateplanlevelrates;
Thepercentoftotalpremiumthatrepresentsessen alhealthbenefitsincludedinWorksheet2,
SectionsIIIandIVwascalculatedinaccordancewithactuarialstandardsofpractice;
TheAVCalculatorwasusedtodeterminetheAVMetalValuesshowninWorksheet2ofthePartI
UnifiedRateReviewTemplateforallplans;
Thehealthbenefitplansprescrip ondrugbenefitcomplieswiththefinalruleonStandardsRelated
toEssentialHealthBenefits,ActuarialValue,andAccreditation;
TheproposedratesweredevelopedincompliancewithallapplicableActuarialStandardsofPrac ce.
ThisopinionisqualifiedasthePartIUnifiedRateReviewTemplate(URRT)doesnotdemonstratethe
processusedbytheissuertodeveloptherates.TheURRTrepresentsinformationrequiredbyFederal
regulationtosupportthereviewofpremiumimpactsandforcertificationthattheindexrateisdeveloped
inaccordancewithFederalregulationandusedconsistentlyandonlyadjustedbytheallowablemodifiers.
Scott D Haglund
Digitally signed by Scott D Haglund

DN: cn=Scott D Haglund, o=Federated
Mutual Insurance Company, ou,
email=sdhaglund@fedins.com, c=US
Date: 2014.10.23 13:38:26 -05'00'
ScottD.Haglund,FSA,MAAA
VicePresidentandDirector,ActuarialServicesLife&Health
FederatedMutualInsuranceCompany
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Rate Filing for Federated Mutual Insurance Company
State of Missouri
Policy Form #: GH 24 10 (01-14 ed.)
Attachment A - Consumer Adjusted Index Rate
Effective Date
Trend
01/01/2015
1.0000
As of 01/01/2015
Sample Rate Calculation
04/01/2015
1.0099
Plan 1409A
07/01/2015
1.0198
Age 40
10/01/2015
1.0299
$294.14
1.278
$375.91
Tobacco Use*
1.000
$375.91
Geo Rating Area 4 x
1.040
Individual Rate
MO-201501
Premium
Maximum of 3 children under 21 yrs.

charged per family
$390.94
Plan
Metal Level
Plan
Metal Level
Premium
Plan
Metal Level
Age
Age
Tobacco
1401A
Platinum
330.64
1401C
Platinum
$ 322.76
1401E
Platinum
Premium
258.90
Band
Factor
Factor
1402A
Gold
290.72
1402C
Gold
$ 281.55
1402E
Gold
236.13
0-17
0.635
1.00
1403A
Gold
292.74
1403C
Gold
$ 278.31
1403E
Gold
339.12
18
0.635
1.00
1404A
Silver
255.36
1404C
Silver
$ 253.84
1404E
Silver
306.19
19
0.635
1.00
1405A
Silver
252.42
1405C
Silver
$ 364.56
1405E
Silver
301.68
20
0.635
1.00
1406A
Bronze
230.22
1406C
Bronze
$ 329.15
1406E
Bronze
300.70
21
1.000
1.00
1407A
Platinum
330.64
1407C
Platinum
$ 324.31
1407E
Platinum
265.38
22
1.000
1.00
1408A
Gold
298.53
1408C
Gold
$ 323.26
1408E
Gold
303.21
23
1.000
1.00
1409A
Gold
294.14
1409C
Gold
$ 285.28
1409E
Gold
262.40
24
1.000
1.00
1410A
Gold
293.19
1410C
Gold
$ 325.96
1410E
Gold
262.46
25
1.004
1.00
1411A
Silver
258.74
1411C
Silver
$ 282.08
1411E
Silver
220.89
26
1.024
1.00
1412A
Gold
295.63
1412C
Gold
$ 282.15
1412E
Gold
336.15
27
1.048
1.00
1413A
Silver
255.84
1413C
Silver
$ 237.46
1413E
Silver
300.24
28
1.087
1.00
1414A
Silver
255.90
1414C
Silver
$ 361.36
1414E
Silver
261.60
29
1.119
1.00
1415A
Bronze
215.37
1415C
Bronze
$ 322.76
1415E
Bronze
258.98
30
1.135
1.00
1416A
Platinum
327.74
1416C
Platinum
$ 281.22
1416E
Platinum
312.30
31
1.159
1.00
1417A
Gold
292.74
1417C
Gold
$ 278.40
1417E
Gold
271.34
32
1.183
1.00
1418A
Silver
255.06
1418C
Silver
$ 335.72
1418E
Silver
268.32
33
1.198
1.00
1501A
Platinum
236.13
1501C
Platinum
$ 271.34
1501E
Platinum
258.98
34
1.214
1.00
1502A
Gold
220.89
1502C
Gold
$ 268.32
1502E
Gold
312.30
35
1.222
1.00
1503A
Gold
312.13
1503C
Gold
$ 236.13
1503E
Gold
271.34
36
1.230
1.00
1504A
Silver
309.16
1504C
Silver
$ 220.89
1504E
Silver
268.32
37
1.238
1.00
1505A
Silver
298.66
1505C
Silver
$ 312.13
1505E
Silver
236.13
38
1.246
1.00
1506A
Bronze
268.32
1506C
Bronze
$ 309.16
1506E
Bronze
220.89
39
1.262
1.00
1507A
Platinum
259.38
1507C
Platinum
$ 298.66
1507E
Platinum
312.13
40
1.278
1.00
1508A
Gold
264.92
1508C
Gold
$ 268.32
1508E
Gold
309.16
41
1.302
1.00
1509A
Gold
274.21
1509C
Gold
$ 259.38
1509E
Gold
298.66
42
1.325
1.00
1510A
Gold
220.89
1510C
Gold
$ 264.92
1510E
Gold
268.32
43
1.357
1.00
1511A
Silver
220.89
1511C
Silver
$ 274.21
1511E
Silver
259.38
44
1.397
1.00
1512A
Gold
231.80
1512C
Gold
$ 220.89
1512E
Gold
264.92
45
1.444
1.00
1513A
Silver
339.12
1513C
Silver
$ 220.89
1513E
Silver
274.21
46
1.500
1.00
1514A
Silver
298.18
1514C
Silver
$ 231.80
1514E
Silver
220.89
47
1.563
1.00
1515A
Bronze
300.24
1515C
Bronze
$ 339.12
1515E
Bronze
220.89
48
1.635
1.00
1516A
Platinum
261.91
1516C
Platinum
$ 298.18
1516E
Platinum
231.80
49
1.706
1.00
1401B
Platinum
252.50
1401D
Platinum
$ 291.69
50
1.786
1.00
1402B
Gold
304.49
1402D
Gold
$ 288.44
51
1.865
1.00
1403B
Gold
264.56
1403D
Gold
$ 253.84
52
1.952
1.00
1404B
Silver
261.61
1404D
Silver
$ 237.46
53
2.040
1.00
1405B
Silver
230.22
1405D
Silver
$ 335.54
54
2.135
1.00
1406B
Bronze
215.37
1406D
Bronze
$ 332.35
55
2.230
1.00
1407B
Platinum
304.33
1407D
Platinum
$ 321.06
Area
Factor
56
2.333
1.00
1408B
Gold
301.43
1408D
Gold
$ 288.44
Rating Area 1
0.980
57
2.437
1.00
1409B
Gold
291.20
1409D
Gold
$ 278.83
Rating Area 2
0.980
58
2.548
1.00
1410B
Gold
261.61
1410D
Gold
$ 284.79
Rating Area 3
1.040
59
2.603
1.00
1411B
Silver
252.89
1411D
Silver
$ 294.78
Rating Area 4
1.040
60
2.714
1.00
1412B
Gold
258.29
1412D
Gold
$ 237.46
Rating Area 5
0.960
61
2.810
1.00
1413B
Silver
267.36
1413D
Silver
$ 237.46
Rating Area 6
1.000
62
2.873
1.00
1414B
Silver
215.37
1414D
Silver
$ 249.19
Rating Area 7
0.900
63
2.952
1.00
1415B
Bronze
215.37
1415D
Bronze
$ 339.12
Rating Area 8
0.960
64+
3.000
1.00
1416B
Platinum
226.01
1416D
Platinum
$ 298.18
Rating Area 9
1.010
1417B
Gold
364.56
1417D
Gold
$ 300.24
Rating Area 10
1.000
1418B
Silver
320.54
1418D
Silver
$ 261.91
1501B
Platinum
258.90
1501D
Platinum
$ 300.24
1502B
Gold
236.13
1502D
Gold
$ 261.91
1503B
Gold
339.12
1503D
Gold
$ 258.90
1504B
Silver
306.19
1504D
Silver
$ 236.13
1505B
Silver
301.68
1505D
Silver
$ 339.12
1506B
Bronze
300.70
1506D
Bronze
$ 306.19
1507B
Platinum
265.38
1507D
Platinum
$ 301.68
1508B
Gold
303.21
1508D
Gold
$ 300.70
1509B
Gold
262.40
1509D
Gold
$ 265.38
1510B
Gold
262.46
1510D
Gold
$ 303.21
1511B
Silver
220.89
1511D
Silver
$ 262.40
1512B
Gold
336.15
1512D
Gold
$ 262.46
1513B
Silver
300.24
1513D
Silver
$ 220.89
1514B
Silver
261.60
1514D
Silver
$ 336.15
1515B
Bronze
258.98
1515D
Bronze
$ 300.24
1516B
Platinum
312.30
1516D
Platinum
$ 261.60
Geographic Factors
Network A is available statewide
Network B is available in Rating Areas 1, 4, 5, and 7 - 9
Network C is avaliable in Rating Areas 2 and 4 - 10
Network D is avaliable in Rating Areas 3, 4, and 7 - 9
Network E is avaliable in Rating Areas 1, 3 - 5, 7, and 8
A-1
09/09/2014
State of Missouri
Attachment A - Plan Designs
Plan Name
MO-201501
Metal Level Network
Deductible
OON Deductible
Family
Deductible
OON - Family
Deductible
OOP Max
OON - OOP
Family OOP
OON - Family OOP
Coins
OON - Coins
OV Copay
SpOV Copay
Rx
Emergency
1401A
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
$20
$20
10/30/60/150
$100
1402A
Gold
$1,000
$1,000
$2,000
$2,000
$4,000
$8,000
$8,000
$16,000
85%
60%
$40
$40
12/40/70/175
$200
1403A
Gold
$600
$600
$1,200
$1,200
$4,600
$9,200
$9,200
$18,400
80%
55%
12/40/70/175
1404A
Silver
$1,500
$1,500
$3,000
$3,000
$5,500
$8,250
$11,000
$16,500
70%
50%
16/60/90/225
1405A
Silver
$2,000
$2,000
$4,000
$4,000
$5,500
$9,875
$11,000
$19,750
80%
55%
16/60/90/225
1406A
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
20/80/120/300
1407A
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
15%
15%
10/30/60/150
15%
1408A
Gold
$500
$500
$1,000
$1,000
$5,000
$7,500
$10,000
$15,000
70%
50%
20%
20%
12/40/70/175
20%
1409A
Gold
$1,000
$1,000
$2,000
$2,000
$5,500
$11,000
$11,000
$22,000
80%
55%
20%
20%
12/40/70/175
20%
1410A
Gold
$1,500
$1,500
$3,000
$3,000
$4,500
$8,250
$9,000
$16,500
80%
55%
20%
20%
12/40/70/175
20%
1411A
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
35%
35%
16/60/90/225
35%
1412A
Gold
$1,300
$1,300
$2,600
$2,600
$2,500
$4,500
$5,000
$9,000
85%
60%
1413A
Silver
$1,750
$1,750
$3,500
$3,500
$5,000
$7,500
$10,000
$15,000
70%
50%
1414A
Silver
$2,000
$2,000
$4,000
$4,000
$6,000
$11,000
$12,000
$22,000
80%
55%
1415A
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
1416A
Platinum
$0
$0
$0
$0
$1,500
$3,000
$3,000
$6,000
80%
55%
$20
$20
10/30/60/150
$150
1417A
Gold
$1,000
$1,000
$2,000
$2,000
$3,450
$7,000
$6,900
$14,000
80%
55%
$40
$40
12/40/70/175
$200
1418A
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
$50
$50
16/60/90/225
$400
1501A
Silver
$3,000
$3,000
$6,000
$6,000
$6,600
$13,200
$13,200
$26,400
80%
60%
$40
$300
16/60/90/225
$300
1502A
Gold
$0
$0
$0
$0
$3,200
$12,800
$6,400
$25,600
50%
50%
1503A
Silver
$0
$0
$0
$0
$6,600
$13,200
$13,200
$26,400
50%
50%
1504A
Silver
$3,000
$3,000
$6,000
$6,000
$4,500
$9,000
$9,000
$18,000
80%
60%
3free
16/60/90/225
1505A
Bronze
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
25/95/150/300
1506A
Bronze
$6,600
$6,600
$13,200
$13,200
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
1507A
Gold
$1,000
$1,000
$2,000
$2,000
$3,250
$6,500
$6,500
$13,000
80%
60%
20%
20%
12/40/70/175
20%
1508A
Gold
$2,000
$2,000
$4,000
$4,000
$3,000
$6,000
$6,000
$12,000
100%
75%
20%
20%
12/40/70/175
20%
1509A
Gold
$2,000
$2,000
$4,000
$4,000
$4,000
$8,000
$8,000
$16,000
80%
60%
20%
20%
12/40/70/175
20%
1510A
Silver
$3,500
$3,500
$7,000
$7,000
$6,250
$12,500
$12,500
$25,000
80%
60%
20%
20%
16/60/90/225
20%
1511A
Silver
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
80%
60%
20%
20%
16/60/90/225
20%
1512A
Silver
$2,750
$2,750
$5,500
$5,500
$3,750
$7,500
$7,500
$15,000
80%
60%
1513A
Silver
$3,000
$3,000
$6,000
$6,000
$3,000
$6,000
$6,000
$12,000
100%
75%
1514A
Bronze
$6,000
$6,000
$12,000
$12,000
$6,000
$12,000
$12,000
$24,000
100%
75%
1515A
Bronze
$6,300
$6,300
$12,600
$12,600
$6,300
$12,600
$12,600
$25,200
100%
70%
1516A
Bronze
$4,000
$4,000
$8,000
$8,000
$6,600
$13,200
$13,200
$26,400
70%
50%
A-2
Deduct./Coins.; Specialty
max $175
max $225
max $225
max $300
12/40/70/175
16/60/90/225
20/80/120/300
max $225
max $225
max $300
max $300
$60
$500
25/95/150/300
$500
09/09/2014
State of Missouri
Plan Name
MO-201501
Metal Level Network
Deductible
OON Deductible
Family
Deductible
OON - Family
Deductible
OOP Max
OON - OOP
Family OOP
OON - Family OOP
Coins
OON - Coins
OV Copay
SpOV Copay
Rx
Emergency
1401B
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
$20
$20
10/30/60/150
$100
1402B
Gold
$1,000
$1,000
$2,000
$2,000
$4,000
$8,000
$8,000
$16,000
85%
60%
$40
$40
12/40/70/175
$200
1403B
Gold
$600
$600
$1,200
$1,200
$4,600
$9,200
$9,200
$18,400
80%
55%
12/40/70/175
1404B
Silver
$1,500
$1,500
$3,000
$3,000
$5,500
$8,250
$11,000
$16,500
70%
50%
16/60/90/225
1405B
Silver
$2,000
$2,000
$4,000
$4,000
$5,500
$9,875
$11,000
$19,750
80%
55%
16/60/90/225
1406B
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
20/80/120/300
1407B
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
15%
15%
10/30/60/150
15%
1408B
Gold
$500
$500
$1,000
$1,000
$5,000
$7,500
$10,000
$15,000
70%
50%
20%
20%
12/40/70/175
20%
1409B
Gold
$1,000
$1,000
$2,000
$2,000
$5,500
$11,000
$11,000
$22,000
80%
55%
20%
20%
12/40/70/175
20%
1410B
Gold
$1,500
$1,500
$3,000
$3,000
$4,500
$8,250
$9,000
$16,500
80%
55%
20%
20%
12/40/70/175
20%
1411B
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
35%
35%
16/60/90/225
35%
1412B
Gold
$1,300
$1,300
$2,600
$2,600
$2,500
$4,500
$5,000
$9,000
85%
60%
1413B
Silver
$1,750
$1,750
$3,500
$3,500
$5,000
$7,500
$10,000
$15,000
70%
50%
1414B
Silver
$2,000
$2,000
$4,000
$4,000
$6,000
$11,000
$12,000
$22,000
80%
55%
1415B
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
1416B
Platinum
$0
$0
$0
$0
$1,500
$3,000
$3,000
$6,000
80%
55%
$20
$20
10/30/60/150
$150
1417B
Gold
$1,000
$1,000
$2,000
$2,000
$3,450
$7,000
$6,900
$14,000
80%
55%
$40
$40
12/40/70/175
$200
1418B
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
$50
$50
16/60/90/225
$400
1501B
Silver
$3,000
$3,000
$6,000
$6,000
$6,600
$13,200
$13,200
$26,400
80%
60%
$40
$300
16/60/90/225
$300
1502B
Gold
$0
$0
$0
$0
$3,200
$12,800
$6,400
$25,600
50%
50%
1503B
Silver
$0
$0
$0
$0
$6,600
$13,200
$13,200
$26,400
50%
50%
1504B
Silver
$3,000
$3,000
$6,000
$6,000
$4,500
$9,000
$9,000
$18,000
80%
60%
3free
16/60/90/225
1505B
Bronze
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
25/95/150/300
1506B
Bronze
$6,600
$6,600
$13,200
$13,200
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
1507B
Gold
$1,000
$1,000
$2,000
$2,000
$3,250
$6,500
$6,500
$13,000
80%
60%
20%
20%
12/40/70/175
20%
1508B
Gold
$2,000
$2,000
$4,000
$4,000
$3,000
$6,000
$6,000
$12,000
100%
75%
20%
20%
12/40/70/175
20%
1509B
Gold
$2,000
$2,000
$4,000
$4,000
$4,000
$8,000
$8,000
$16,000
80%
60%
20%
20%
12/40/70/175
20%
1510B
Silver
$3,500
$3,500
$7,000
$7,000
$6,250
$12,500
$12,500
$25,000
80%
60%
20%
20%
16/60/90/225
20%
1511B
Silver
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
80%
60%
20%
20%
16/60/90/225
20%
1512B
Silver
$2,750
$2,750
$5,500
$5,500
$3,750
$7,500
$7,500
$15,000
80%
60%
1513B
Silver
$3,000
$3,000
$6,000
$6,000
$3,000
$6,000
$6,000
$12,000
100%
75%
1514B
Bronze
$6,000
$6,000
$12,000
$12,000
$6,000
$12,000
$12,000
$24,000
100%
75%
1515B
Bronze
$6,300
$6,300
$12,600
$12,600
$6,300
$12,600
$12,600
$25,200
100%
70%
1516B
Bronze
$4,000
$4,000
$8,000
$8,000
$6,600
$13,200
$13,200
$26,400
70%
50%
A-3
max $175
max $225
max $225
max $300
12/40/70/175
16/60/90/225
20/80/120/300
max $225
max $225
max $300
max $300
$60
$500
25/95/150/300
$500
09/09/2014
State of Missouri
Plan Name
MO-201501
Metal Level Network
Deductible
OON Deductible
Family
Deductible
OON - Family
Deductible
OOP Max
OON - OOP
Family OOP
OON - Family OOP
Coins
OON - Coins
OV Copay
SpOV Copay
Rx
Emergency
1401C
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
$20
$20
10/30/60/150
$100
1402C
Gold
$1,000
$1,000
$2,000
$2,000
$4,000
$8,000
$8,000
$16,000
85%
60%
$40
$40
12/40/70/175
$200
1403C
Gold
$600
$600
$1,200
$1,200
$4,600
$9,200
$9,200
$18,400
80%
55%
12/40/70/175
1404C
Silver
$1,500
$1,500
$3,000
$3,000
$5,500
$8,250
$11,000
$16,500
70%
50%
16/60/90/225
1405C
Silver
$2,000
$2,000
$4,000
$4,000
$5,500
$9,875
$11,000
$19,750
80%
55%
16/60/90/225
1406C
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
20/80/120/300
1407C
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
15%
15%
10/30/60/150
15%
1408C
Gold
$500
$500
$1,000
$1,000
$5,000
$7,500
$10,000
$15,000
70%
50%
20%
20%
12/40/70/175
20%
1409C
Gold
$1,000
$1,000
$2,000
$2,000
$5,500
$11,000
$11,000
$22,000
80%
55%
20%
20%
12/40/70/175
20%
1410C
Gold
$1,500
$1,500
$3,000
$3,000
$4,500
$8,250
$9,000
$16,500
80%
55%
20%
20%
12/40/70/175
20%
1411C
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
$0
$0
16/60/90/225
$0
1412C
Gold
$1,300
$1,300
$2,600
$2,600
$2,500
$4,500
$5,000
$9,000
85%
60%
1413C
Silver
$1,750
$1,750
$3,500
$3,500
$5,000
$7,500
$10,000
$15,000
70%
50%
1414C
Silver
$2,000
$2,000
$4,000
$4,000
$6,000
$11,000
$12,000
$22,000
80%
55%
1415C
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
1416C
Platinum
$0
$0
$0
$0
$1,500
$3,000
$3,000
$6,000
80%
55%
$20
$20
10/30/60/150
$150
1417C
Gold
$1,000
$1,000
$2,000
$2,000
$3,450
$7,000
$6,900
$14,000
80%
55%
$40
$40
12/40/70/175
$200
1418C
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
$50
$50
16/60/90/225
$400
1501C
Silver
$3,000
$3,000
$6,000
$6,000
$6,600
$13,200
$13,200
$26,400
80%
60%
$40
$300
16/60/90/225
$300
1502C
Gold
$0
$0
$0
$0
$3,200
$12,800
$6,400
$25,600
50%
50%
1503C
Silver
$0
$0
$0
$0
$6,600
$13,200
$13,200
$26,400
50%
50%
1504C
Silver
$3,000
$3,000
$6,000
$6,000
$4,500
$9,000
$9,000
$18,000
80%
60%
3free
16/60/90/225
1505C
Bronze
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
25/95/150/300
1506C
Bronze
$6,600
$6,600
$13,200
$13,200
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
1507C
Gold
$1,000
$1,000
$2,000
$2,000
$3,250
$6,500
$6,500
$13,000
80%
60%
20%
20%
12/40/70/175
20%
1508C
Gold
$2,000
$2,000
$4,000
$4,000
$3,000
$6,000
$6,000
$12,000
100%
75%
20%
20%
12/40/70/175
20%
1509C
Gold
$2,000
$2,000
$4,000
$4,000
$4,000
$8,000
$8,000
$16,000
80%
60%
20%
20%
12/40/70/175
20%
1510C
Silver
$3,500
$3,500
$7,000
$7,000
$6,250
$12,500
$12,500
$25,000
80%
60%
20%
20%
16/60/90/225
20%
1511C
Silver
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
80%
60%
$0
$0
16/60/90/225
$0
1512C
Silver
$2,750
$2,750
$5,500
$5,500
$3,750
$7,500
$7,500
$15,000
80%
60%
1513C
Silver
$3,000
$3,000
$6,000
$6,000
$3,000
$6,000
$6,000
$12,000
100%
75%
1514C
Bronze
$6,000
$6,000
$12,000
$12,000
$6,000
$12,000
$12,000
$24,000
100%
75%
1515C
Bronze
$6,300
$6,300
$12,600
$12,600
$6,300
$12,600
$12,600
$25,200
100%
70%
1516C
Bronze
$4,000
$4,000
$8,000
$8,000
$6,600
$13,200
$13,200
$26,400
70%
50%
A-4
max $175
max $225
max $225
max $300
12/40/70/175
16/60/90/225
20/80/120/300
max $225
max $225
max $300
max $300
$60
$500
25/95/150/300
$500
09/09/2014
State of Missouri
Plan Name
MO-201501
Metal Level Network
Deductible
OON Deductible
Family
Deductible
OON - Family
Deductible
OOP Max
OON - OOP
Family OOP
OON - Family OOP
Coins
OON - Coins
OV Copay
SpOV Copay
Rx
Emergency
1401D
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
$20
$20
10/30/60/150
$100
1402D
Gold
$1,000
$1,000
$2,000
$2,000
$4,000
$8,000
$8,000
$16,000
85%
60%
$40
$40
12/40/70/175
$200
1403D
Gold
$600
$600
$1,200
$1,200
$4,600
$9,200
$9,200
$18,400
80%
55%
12/40/70/175
1404D
Silver
$1,500
$1,500
$3,000
$3,000
$5,500
$8,250
$11,000
$16,500
70%
50%
16/60/90/225
1405D
Silver
$2,000
$2,000
$4,000
$4,000
$5,500
$9,875
$11,000
$19,750
80%
55%
16/60/90/225
1406D
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
20/80/120/300
1407D
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
15%
15%
10/30/60/150
15%
1408D
Gold
$500
$500
$1,000
$1,000
$5,000
$7,500
$10,000
$15,000
70%
50%
20%
20%
12/40/70/175
20%
1409D
Gold
$1,000
$1,000
$2,000
$2,000
$5,500
$11,000
$11,000
$22,000
80%
55%
20%
20%
12/40/70/175
20%
1410D
Gold
$1,500
$1,500
$3,000
$3,000
$4,500
$8,250
$9,000
$16,500
80%
55%
$0
$0
12/40/70/175
$0
1411D
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
$0
$0
16/60/90/225
$0
1412D
Gold
$1,300
$1,300
$2,600
$2,600
$2,500
$4,500
$5,000
$9,000
85%
60%
1413D
Silver
$1,750
$1,750
$3,500
$3,500
$5,000
$7,500
$10,000
$15,000
70%
50%
1414D
Silver
$2,000
$2,000
$4,000
$4,000
$6,000
$11,000
$12,000
$22,000
80%
55%
1415D
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
1416D
Platinum
$0
$0
$0
$0
$1,500
$3,000
$3,000
$6,000
80%
55%
$20
$20
10/30/60/150
$150
1417D
Gold
$1,000
$1,000
$2,000
$2,000
$3,450
$7,000
$6,900
$14,000
80%
55%
$40
$40
12/40/70/175
$200
1418D
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
$50
$50
16/60/90/225
$400
1501D
Silver
$3,000
$3,000
$6,000
$6,000
$6,600
$13,200
$13,200
$26,400
80%
60%
$40
$300
16/60/90/225
$300
1502D
Gold
$0
$0
$0
$0
$3,200
$12,800
$6,400
$25,600
50%
50%
1503D
Silver
$0
$0
$0
$0
$6,600
$13,200
$13,200
$26,400
50%
50%
1504D
Silver
$3,000
$3,000
$6,000
$6,000
$4,500
$9,000
$9,000
$18,000
80%
60%
3free
16/60/90/225
1505D
Bronze
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
25/95/150/300
1506D
Bronze
$6,600
$6,600
$13,200
$13,200
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
1507D
Gold
$1,000
$1,000
$2,000
$2,000
$3,250
$6,500
$6,500
$13,000
80%
60%
20%
20%
12/40/70/175
20%
1508D
Gold
$2,000
$2,000
$4,000
$4,000
$3,000
$6,000
$6,000
$12,000
100%
75%
20%
20%
12/40/70/175
20%
1509D
Gold
$2,000
$2,000
$4,000
$4,000
$4,000
$8,000
$8,000
$16,000
80%
60%
20%
20%
12/40/70/175
20%
1510D
Silver
$3,500
$3,500
$7,000
$7,000
$6,250
$12,500
$12,500
$25,000
80%
60%
$0
$0
16/60/90/225
$0
1511D
Silver
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
80%
60%
$0
$0
16/60/90/225
$0
1512D
Silver
$2,750
$2,750
$5,500
$5,500
$3,750
$7,500
$7,500
$15,000
80%
60%
1513D
Silver
$3,000
$3,000
$6,000
$6,000
$3,000
$6,000
$6,000
$12,000
100%
75%
1514D
Bronze
$6,000
$6,000
$12,000
$12,000
$6,000
$12,000
$12,000
$24,000
100%
75%
1515D
Bronze
$6,300
$6,300
$12,600
$12,600
$6,300
$12,600
$12,600
$25,200
100%
70%
1516D
Bronze
$4,000
$4,000
$8,000
$8,000
$6,600
$13,200
$13,200
$26,400
70%
50%
A-5
max $175
max $225
max $225
max $300
12/40/70/175
16/60/90/225
20/80/120/300
max $225
max $225
max $300
max $300
$60
$500
25/95/150/300
$500
09/09/2014
State of Missouri
Plan Name
MO-201501
Metal Level Network
Deductible
OON Deductible
Family
Deductible
OON - Family
Deductible
OOP Max
OON - OOP
Family OOP
OON - Family OOP
Coins
OON - Coins
OV Copay
SpOV Copay
Rx
Emergency
1401E
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
$20
$20
10/30/60/150
$100
1402E
Gold
$1,000
$1,000
$2,000
$2,000
$4,000
$8,000
$8,000
$16,000
85%
60%
$40
$40
12/40/70/175
$200
1403E
Gold
$600
$600
$1,200
$1,200
$4,600
$9,200
$9,200
$18,400
80%
55%
12/40/70/175
1404E
Silver
$1,500
$1,500
$3,000
$3,000
$5,500
$8,250
$11,000
$16,500
70%
50%
16/60/90/225
1405E
Silver
$2,000
$2,000
$4,000
$4,000
$5,500
$9,875
$11,000
$19,750
80%
55%
16/60/90/225
1406E
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
20/80/120/300
1407E
Platinum
$0
$0
$0
$0
$2,500
$5,000
$5,000
$10,000
85%
60%
15%
15%
10/30/60/150
15%
1408E
Gold
$500
$500
$1,000
$1,000
$5,000
$7,500
$10,000
$15,000
70%
50%
20%
20%
12/40/70/175
20%
1409E
Gold
$1,000
$1,000
$2,000
$2,000
$5,500
$11,000
$11,000
$22,000
80%
55%
$0
$0
12/40/70/175
$0
1410E
Gold
$1,500
$1,500
$3,000
$3,000
$4,500
$8,250
$9,000
$16,500
80%
55%
$0
$0
12/40/70/175
$0
1411E
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
$0
$0
16/60/90/225
$0
1412E
Gold
$1,300
$1,300
$2,600
$2,600
$2,500
$4,500
$5,000
$9,000
85%
60%
1413E
Silver
$1,750
$1,750
$3,500
$3,500
$5,000
$7,500
$10,000
$15,000
70%
50%
1414E
Silver
$2,000
$2,000
$4,000
$4,000
$6,000
$11,000
$12,000
$22,000
80%
55%
1415E
Bronze
$5,000
$5,000
$10,000
$10,000
$6,350
$9,600
$12,700
$19,200
70%
50%
1416E
Platinum
$0
$0
$0
$0
$1,500
$3,000
$3,000
$6,000
80%
55%
$20
$20
10/30/60/150
$150
1417E
Gold
$1,000
$1,000
$2,000
$2,000
$3,450
$7,000
$6,900
$14,000
80%
55%
$40
$40
12/40/70/175
$200
1418E
Silver
$2,000
$2,000
$4,000
$4,000
$6,350
$9,600
$12,700
$19,200
70%
50%
$50
$50
16/60/90/225
$400
1501E
Silver
$3,000
$3,000
$6,000
$6,000
$6,600
$13,200
$13,200
$26,400
80%
60%
$40
$300
16/60/90/225
$300
1502E
Gold
$0
$0
$0
$0
$3,200
$12,800
$6,400
$25,600
50%
50%
1503E
Silver
$0
$0
$0
$0
$6,600
$13,200
$13,200
$26,400
50%
50%
1504E
Silver
$3,000
$3,000
$6,000
$6,000
$4,500
$9,000
$9,000
$18,000
80%
60%
3free
16/60/90/225
1505E
Bronze
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
25/95/150/300
1506E
Bronze
$6,600
$6,600
$13,200
$13,200
$6,600
$13,200
$13,200
$26,400
100%
75%
3free
1507E
Gold
$1,000
$1,000
$2,000
$2,000
$3,250
$6,500
$6,500
$13,000
80%
60%
20%
20%
12/40/70/175
20%
1508E
Gold
$2,000
$2,000
$4,000
$4,000
$3,000
$6,000
$6,000
$12,000
100%
75%
20%
20%
12/40/70/175
20%
1509E
Gold
$2,000
$2,000
$4,000
$4,000
$4,000
$8,000
$8,000
$16,000
80%
60%
$0
$0
12/40/70/175
$0
1510E
Silver
$3,500
$3,500
$7,000
$7,000
$6,250
$12,500
$12,500
$25,000
80%
60%
$0
$0
16/60/90/225
$0
1511E
Silver
$5,000
$5,000
$10,000
$10,000
$6,600
$13,200
$13,200
$26,400
80%
60%
$0
$0
16/60/90/225
$0
1512E
Silver
$2,750
$2,750
$5,500
$5,500
$3,750
$7,500
$7,500
$15,000
80%
60%
1513E
Silver
$3,000
$3,000
$6,000
$6,000
$3,000
$6,000
$6,000
$12,000
100%
75%
1514E
Bronze
$6,000
$6,000
$12,000
$12,000
$6,000
$12,000
$12,000
$24,000
100%
75%
1515E
Bronze
$6,300
$6,300
$12,600
$12,600
$6,300
$12,600
$12,600
$25,200
100%
70%
1516E
Bronze
$4,000
$4,000
$8,000
$8,000
$6,600
$13,200
$13,200
$26,400
70%
50%
A-6
max $175
max $225
max $225
max $300
12/40/70/175
16/60/90/225
20/80/120/300
max $225
max $225
max $300
max $300
$60
$500
25/95/150/300
$500
09/09/2014
State of Missouri
Attachment A - Area Definitions
Counties in Area:
1
Andrew
Atchison
Buchanan
Caldwell
Carroll
Clinton
Daviess
De Kalb
Gentry
Grundy
Harrison
Holt
Livingston
Mercer
Nodaway
Ray
Worth
MO-201501
2
Adair
Clark
Knox
Lewis
Linn
Macon
Marion
Pike
Putnam
Ralls
Schuyler
Scotland
Shelby
Sullivan
3
Cass
Clay
Jackson
Platte
4
Bates
Benton
Henry
Johnson
Lafayette
Pettis
Saline
St Clair
Vernon
5
Audrain
Boone
Callaway
Camden
Chariton
Cole
Cooper
Gasconade
Howard
Maries
Miller
Moniteau
Monroe
Montgomery
Morgan
Osage
Randolph
6
Franklin
Jefferson
Lincoln
St Charles
St Francois
St Louis
St Louis City
Ste Genevieve
Warren
Washington
A-7
7
Barton
Jasper
Mc Donald
Newton
8
Barry
Cedar
Christian
Dade
Dallas
Douglas
Greene
Hickory
Laclede
Lawrence
Ozark
Polk
Stone
Taney
Webster
Wright
9
Carter
Crawford
Dent
Howell
Iron
Oregon
Phelps
Pulaski
Reynolds
Ripley
Shannon
Texas
10
Bollinger
Butler
Cape Girardeau
Dunklin
Madison
Mississippi
New Madrid
Pemiscot
Perry
Scott
Stoddard
Wayne
09/09/2014
State of Missouri
Attachment B - Trend Impact on Index Rate
January Effective
Date
Member Months
Projected Allowed Claims
Months of Trend
Annual Trend Rate
Single Risk Pool Projected
Claims (=Base Allowed
Claims*(1+Annual
Trend)^(Months of Trend/12))
Index Rate Entered in
January Template
Effective Date Entered in
January Template
MO-201501
April Effective July Effective October

Date
Date
Effective Date
Total Single
Risk Pool
5,538
5,538
5,538
5,538
22,152
$389.70
$389.70
$389.70
$389.70
$389.70
1.5
4.5
7.5
10.5
4.00%
4.00%
4.00%
4.00%
$391.62
$395.48
$399.37
$403.31
$397.45
$397.45
1/1/2015
B-1
9/9/2014
State of Missouri
Attachment C - Credibility Adjustment Factor

Experience based on Exposure and Claims Incurred 1/1/2013 - 12/31/2013, paid through 3/31/2014.
Step 1: Adjust State-Specific Experience for Large Claims

Nationwide
% of Total
Missouri
Allowed
Charges PMPM
Allowed Charges
Adjusted for
Large Claims
Claim & Benefit

Adjustment to
Projection Period
Trend
Missouri
Projected Allowed
Charges PMPM
Inpatient Hospital
Outpatient Hospital
Professional
Other Medical
Prescription Drug
22.1%
32.2%
27.2%
2.3%
16.2%
55.11
111.19
82.36
9.75
55.30
59.41
113.65
86.12
9.10
56.66
1.109
1.109
1.109
1.109
1.109
1.082
1.082
1.082
1.082
1.082
71.25
136.30
103.28
10.92
67.95
Totals
100.0%
313.71
324.95
1.109
1.082
389.70
E=B*C*D
Service Category
B = Claim levels were capped at a threshold that limited the highest 5% of claims within each service category nationwide and pooled across the block based on membership.
C = Adjustments include changes in expected morbidity, additional covered benefits, and changes to network discount levels
Step 2: Determine Credibility of State-Specific Experience
Service Category
Inpatient Hospital
Outpatient Hospital
Professional
Other Medical
Prescription Drug
Missouri
Member Months
Member Months
Needed for
Full Credibility
Credibility
73,783
73,783
73,783
73,783
73,783
855,328
91,830
27,327
508,461
25,820
29.4%
89.6%
100.0%
38.1%
100.0%
H = (F/G)^(1/2)
F = Member Months needed for full credibility is equal to 1,082 * [1 + (Variance)/(Mean^2)].

("An Introduction to Credibility Theory", by L.H. Longley-Cook)
Step 3: Credibility-Adjust State-Specific Experience

Missouri
Projected Allowed
Charges PMPM
Manual
Allowed
Charges PMPM
Credibility
Missouri
Credibilized Allowed
Charges PMPM
Inpatient Hospital
Outpatient Hospital
Professional
Other Medical
Prescription Drug
71.25
136.30
103.28
10.92
67.95
83.89
122.43
103.31
8.77
61.58
29.4%
89.6%
100.0%
38.1%
100.0%
80.18
134.86
103.28
9.59
67.95
Totals
389.70
379.98
K = E*H + (1-H)*J
Service Category
395.86
Step 4: Calculate Credibility Adjustment Factor for Claims in the Exposure Period
Combined Benefit Category Credibility Manual Weighting = (K-J)/(E-J)
1.000
This is bounded such that the overall adjustment is not less than zero or greater than one based on URRT requirements.
MO-201501
C-1
9/9/2014
State of Missouri
Attachment D - MLR Projection, Federally Prescribed
Projection Period Incurred Claims

Projected Average Premium PMPM
Projected Premium Taxes and Fees
Projected MLR Premium
$6,969,383 [A] URRT Worksheet 1, Line 38

$8,846,853 [B] URRT Worksheet 1, Line 43
$203,596 [C] URRT Worksheet 1, Line 42
$8,643,257 [D] = [B] - [C]
2.30%
Projected MLR before Credibility Adjustment:
80.6% [E] = [A] / [D]
Projected Credibility Adjustment:
2.1% [F]
Projected MLR :
82.7% [G] = [E] + [F]
Projected Incurred Claims / Projected Premium (non MLR)

Projected Incurred Claims
Projected Premium
Projected Incurred Loss Ratio
MO-201501
D-1
$6,969,383 [A]
$8,846,853 [B]
78.8% [H] = [A] / [B]
9/9/2014
State of Missouri
Attachment E - Essential Health Benefits
Benefits
Primary Care Visit to Treat an Injury or Illness
Specialist Visit
Other Practitioner Office Visit (Nurse, Physician
Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery
Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Non-Emergency Care When Traveling Outside the U.S.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Home Health Care Services
Emergency Room Services
Emergency Transportation/Ambulance
Inpatient Hospital Services (e.g., Hospital Stay)
Inpatient Physician and Surgical Services
Bariatric Surgery
MO201501
Is this Benefit
Covered?
Quantitative Limit on
Limit Quantity
Service
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Limit Unit
Not Covered
Not Covered
Not Covered
Not Covered
Covered
no
Not Covered
Covered
no
Covered
yes
Covered
no
Covered
no
Covered
no
Covered
no
90
visits per year
Not Covered
E1
07/10/2014
State of Missouri
Benefits
Cosmetic Surgery
Skilled Nursing Facility
Prenatal and Postnatal Care
Delivery and All Inpatient Services for Maternity Care
Mental/Behavioral Health Outpatient Services
Mental/Behavioral Health Inpatient Services
Substance Abuse Disorder Outpatient Services
Substance Abuse Disorder Inpatient Services
Generic Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Specialty Drugs
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
MO201501
Is this Benefit
Covered?
Limit Quantity
Service
Limit Unit
Not Covered
Covered
yes
90
days per year
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
yes
Covered
yes
20
OT 20 visits, PT 20 visits
Covered
yes
26
visits per year
Covered
no
cardiac rehab 36 sessions; OT 20 visits, PT

20 visits; pulmonary 20 visits;
Not Covered
Covered
no
Covered
no
E2
07/10/2014
State of Missouri
Benefits
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Eye Glasses for Children
Dental Check-Up for Children
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical
Therapy
Well Baby Visits and Care
Laboratory Outpatient and Professional Services
X-rays and Diagnostic Imaging
Basic Dental Care Child
Orthodontia Child
Major Dental Care Child
Basic Dental Care Adult
Orthodontia Adult
Major Dental Care Adult
Abortion for Which Public Funding is Prohibited
Transplant
MO201501
Is this Benefit
Covered?
Limit Quantity
Service
Limit Unit
Not Covered
Not Covered
Not Covered
Covered
yes
Covered
yes
Not Covered
exam per year

pair lenses per year and 1 frame every other
year
Covered in bundled dental policy
Covered
no
Covered
yes
Covered
no
Covered
no
Covered
no
20
OT 20 visits, PT 20 visits
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Covered
no
E3
07/10/2014
State of Missouri
Benefits
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
Clinical Trials
Inherited Metabolic Disorder - PKU
Dental Anesthesia
Bone Marrow Testing
Applied Behavior Analysis Based Therapies
Newborn Services Other
MO201501
Is this Benefit
Covered?
Limit Quantity
Service
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
Covered
no
E4
Limit Unit
07/10/2014
State of Missouri
Small Group Policy Form #: GH 24 10 (01-14 ed.)
Attachment F - Claims Experience Table
MO Allowed
Claims
Medical Claims
Pharmacy Claims
Incurred but Not
Reported as of
3/31/2014
Total Claim
Estimate
MO-201501
MO Paid
Claims
Natl Allowed
Claims
Natl Paid Claims
$18,730,923
$14,343,053
$236,224,389
$181,339,210
$4,073,512
$3,218,846
$46,328,440
$35,771,859
$342,006
$404,767
$3,806,084
$4,840,120
$23,146,441
$17,966,666
$286,358,914
$221,951,189
F-1
7/14/2014
State of Missouri
Attachment G: Rate Development and Calibration
[A]
Plan Name
1401A
1402A
1403A
1404A
1405A
1406A
1407A
1408A
1409A
1410A
1411A
1412A
1413A
1414A
1415A
1416A
1417A
1418A
1501A
1502A
1503A
1504A
1505A
1506A
1507A
1508A
1509A
1510A
1511A
1512A
1513A
MO-201501
HIOS Plan ID Metallic Tier

64701MO0030001
Platinum
64701MO0030002
Gold
64701MO0030003
Gold
64701MO0030004
Silver
64701MO0030005
Silver
64701MO0030006
Bronze
64701MO0030007
Platinum
64701MO0030008
Gold
64701MO0030009
Gold
64701MO0030010
Gold
64701MO0030011
Silver
64701MO0030012
Gold
64701MO0030013
Silver
64701MO0030014
Silver
64701MO0030015
Bronze
64701MO0030016
Platinum
64701MO0030017
Gold
64701MO0030018
Silver
64701MO0030091
Silver
64701MO0030092
Gold
64701MO0030093
Silver
64701MO0030094
Silver
64701MO0030095
Bronze
64701MO0030096
Bronze
64701MO0030097
Gold
64701MO0030098
Gold
64701MO0030099
Gold
64701MO0030100
Silver
64701MO0030101
Silver
64701MO0030102
Silver
64701MO0030103
Silver
Member Projected Index

Months
Rate
37
$389.70
35
$389.70
35
$389.70
34
$389.70
34
$389.70
24
$389.70
37
$389.70
35
$389.70
35
$389.70
35
$389.70
34
$389.70
35
$389.70
34
$389.70
34
$389.70
24
$389.70
37
$389.70
35
$389.70
34
$389.70
34
$389.70
35
$389.70
34
$389.70
34
$389.70
24
$389.70
24
$389.70
35
$389.70
35
$389.70
35
$389.70
34
$389.70
34
$389.70
34
$389.70
34
$389.70
[B] = Wksh 1,
V35 / Wksh 1,
V33
Risk Adjustment
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
G-1
[C] = Wksh 1,
V37 / Wksh 1,
V33
Transitional
Reinsurance
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
[D] = [A]+[B]+[C]
Market Adjusted
Index Rate
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
9/9/2014
State of Missouri
[A]
Plan Name
1514A
1515A
1516A
1401B
1402B
1403B
1404B
1405B
1406B
1407B
1408B
1409B
1410B
1411B
1412B
1413B
1414B
1415B
1416B
1417B
1418B
1501B
1502B
1503B
1504B
1505B
1506B
1507B
1508B
1509B
1510B
MO-201501

64701MO0030104
Bronze
64701MO0030105
Bronze
64701MO0030106
Bronze
64701MO0030019
Platinum
64701MO0030020
Gold
64701MO0030021
Gold
64701MO0030022
Silver
64701MO0030023
Silver
64701MO0030024
Bronze
64701MO0030025
Platinum
64701MO0030026
Gold
64701MO0030027
Gold
64701MO0030028
Gold
64701MO0030029
Silver
64701MO0030030
Gold
64701MO0030031
Silver
64701MO0030032
Silver
64701MO0030033
Bronze
64701MO0030034
Platinum
64701MO0030035
Gold
64701MO0030036
Silver
64701MO0030107
Silver
64701MO0030108
Gold
64701MO0030109
Silver
64701MO0030110
Silver
64701MO0030111
Bronze
64701MO0030112
Bronze
64701MO0030113
Gold
64701MO0030114
Gold
64701MO0030115
Gold
64701MO0030116
Silver

Months
Rate
24
$389.70
24
$389.70
24
$389.70
37
$389.70
35
$389.70
35
$389.70
34
$389.70
34
$389.70
24
$389.70
37
$389.70
35
$389.70
35
$389.70
35
$389.70
34
$389.70
35
$389.70
34
$389.70
34
$389.70
24
$389.70
37
$389.70
35
$389.70
34
$389.70
34
$389.70
35
$389.70
34
$389.70
34
$389.70
24
$389.70
24
$389.70
35
$389.70
35
$389.70
35
$389.70
34
$389.70
[B] = Wksh 1,
V35 / Wksh 1,
V33
Risk Adjustment
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
G-2
[C] = Wksh 1,
V37 / Wksh 1,
V33
Transitional
Reinsurance
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
[D] = [A]+[B]+[C]
Market Adjusted
Index Rate
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
9/9/2014
State of Missouri
[A]
Plan Name
1511B
1512B
1513B
1514B
1515B
1516B
1401C
1402C
1403C
1404C
1405C
1406C
1407C
1408C
1409C
1410C
1411C
1412C
1413C
1414C
1415C
1416C
1417C
1418C
1501C
1502C
1503C
1504C
1505C
1506C
1507C
MO-201501

64701MO0030117
Silver
64701MO0030118
Silver
64701MO0030119
Silver
64701MO0030120
Bronze
64701MO0030121
Bronze
64701MO0030122
Bronze
64701MO0030037
Platinum
64701MO0030038
Gold
64701MO0030039
Gold
64701MO0030040
Silver
64701MO0030041
Silver
64701MO0030042
Bronze
64701MO0030043
Platinum
64701MO0030044
Gold
64701MO0030045
Gold
64701MO0030046
Gold
64701MO0030047
Silver
64701MO0030048
Gold
64701MO0030049
Silver
64701MO0030050
Silver
64701MO0030051
Bronze
64701MO0030052
Platinum
64701MO0030053
Gold
64701MO0030054
Silver
64701MO0030123
Silver
64701MO0030124
Gold
64701MO0030125
Silver
64701MO0030126
Silver
64701MO0030127
Bronze
64701MO0030128
Bronze
64701MO0030129
Gold

Months
Rate
34
$389.70
34
$389.70
34
$389.70
24
$389.70
24
$389.70
24
$389.70
443
$389.70
423
$389.70
423
$389.70
409
$389.70
409
$389.70
285
$389.70
443
$389.70
423
$389.70
423
$389.70
423
$389.70
409
$389.70
423
$389.70
409
$389.70
409
$389.70
285
$389.70
443
$389.70
423
$389.70
409
$389.70
409
$389.70
423
$389.70
409
$389.70
409
$389.70
285
$389.70
285
$389.70
423
$389.70
[B] = Wksh 1,
V35 / Wksh 1,
V33
Risk Adjustment
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
G-3
[C] = Wksh 1,
V37 / Wksh 1,
V33
Transitional
Reinsurance
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
[D] = [A]+[B]+[C]
Market Adjusted
Index Rate
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
9/9/2014
State of Missouri
[A]
Plan Name
1508C
1509C
1510C
1511C
1512C
1513C
1514C
1515C
1516C
1401D
1402D
1403D
1404D
1405D
1406D
1407D
1408D
1409D
1410D
1411D
1412D
1413D
1414D
1415D
1416D
1417D
1418D
1501D
1502D
1503D
1504D
MO-201501

64701MO0030130
Gold
64701MO0030131
Gold
64701MO0030132
Silver
64701MO0030133
Silver
64701MO0030134
Silver
64701MO0030135
Silver
64701MO0030136
Bronze
64701MO0030137
Bronze
64701MO0030138
Bronze
64701MO0030055
Platinum
64701MO0030056
Gold
64701MO0030057
Gold
64701MO0030058
Silver
64701MO0030059
Silver
64701MO0030060
Bronze
64701MO0030061
Platinum
64701MO0030062
Gold
64701MO0030063
Gold
64701MO0030064
Gold
64701MO0030065
Silver
64701MO0030066
Gold
64701MO0030067
Silver
64701MO0030068
Silver
64701MO0030069
Bronze
64701MO0030070
Platinum
64701MO0030071
Gold
64701MO0030072
Silver
64701MO0030139
Silver
64701MO0030140
Gold
64701MO0030141
Silver
64701MO0030142
Silver

Months
Rate
423
$389.70
423
$389.70
409
$389.70
409
$389.70
409
$389.70
409
$389.70
285
$389.70
285
$389.70
285
$389.70
74
$389.70
70
$389.70
70
$389.70
68
$389.70
68
$389.70
47
$389.70
74
$389.70
70
$389.70
70
$389.70
70
$389.70
68
$389.70
70
$389.70
68
$389.70
68
$389.70
47
$389.70
74
$389.70
70
$389.70
68
$389.70
68
$389.70
70
$389.70
68
$389.70
68
$389.70
[B] = Wksh 1,
V35 / Wksh 1,
V33
Risk Adjustment
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
G-4
[C] = Wksh 1,
V37 / Wksh 1,
V33
Transitional
Reinsurance
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
[D] = [A]+[B]+[C]
Market Adjusted
Index Rate
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
9/9/2014
State of Missouri
[A]
Plan Name
1505D
1506D
1507D
1508D
1509D
1510D
1511D
1512D
1513D
1514D
1515D
1516D
1401E
1402E
1403E
1404E
1405E
1406E
1407E
1408E
1409E
1410E
1411E
1412E
1413E
1414E
1415E
1416E
1417E
1418E
1501E
MO-201501

64701MO0030143
Bronze
64701MO0030144
Bronze
64701MO0030145
Gold
64701MO0030146
Gold
64701MO0030147
Gold
64701MO0030148
Silver
64701MO0030149
Silver
64701MO0030150
Silver
64701MO0030151
Silver
64701MO0030152
Bronze
64701MO0030153
Bronze
64701MO0030154
Bronze
64701MO0030073
Platinum
64701MO0030074
Gold
64701MO0030075
Gold
64701MO0030076
Silver
64701MO0030077
Silver
64701MO0030078
Bronze
64701MO0030079
Platinum
64701MO0030080
Gold
64701MO0030081
Gold
64701MO0030082
Gold
64701MO0030083
Silver
64701MO0030084
Gold
64701MO0030085
Silver
64701MO0030086
Silver
64701MO0030087
Bronze
64701MO0030088
Platinum
64701MO0030089
Gold
64701MO0030090
Silver
64701MO0030155
Silver

Months
Rate
47
$389.70
47
$389.70
70
$389.70
70
$389.70
70
$389.70
68
$389.70
68
$389.70
68
$389.70
68
$389.70
47
$389.70
47
$389.70
47
$389.70
148
$389.70
141
$389.70
141
$389.70
136
$389.70
136
$389.70
95
$389.70
148
$389.70
141
$389.70
141
$389.70
141
$389.70
136
$389.70
141
$389.70
136
$389.70
136
$389.70
95
$389.70
148
$389.70
141
$389.70
136
$389.70
136
$389.70
[B] = Wksh 1,
V35 / Wksh 1,
V33
Risk Adjustment
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
G-5
[C] = Wksh 1,
V37 / Wksh 1,
V33
Transitional
Reinsurance
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
[D] = [A]+[B]+[C]
Market Adjusted
Index Rate
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
9/9/2014
State of Missouri
[A]
Plan Name
1502E
1503E
1504E
1505E
1506E
1507E
1508E
1509E
1510E
1511E
1512E
1513E
1514E
1515E
1516E
MO-201501

64701MO0030156
Gold
64701MO0030157
Silver
64701MO0030158
Silver
64701MO0030159
Bronze
64701MO0030160
Bronze
64701MO0030161
Gold
64701MO0030162
Gold
64701MO0030163
Gold
64701MO0030164
Silver
64701MO0030165
Silver
64701MO0030166
Silver
64701MO0030167
Silver
64701MO0030168
Bronze
64701MO0030169
Bronze
64701MO0030170
Bronze

Months
Rate
141
$389.70
136
$389.70
136
$389.70
95
$389.70
95
$389.70
141
$389.70
141
$389.70
141
$389.70
136
$389.70
136
$389.70
136
$389.70
136
$389.70
95
$389.70
95
$389.70
95
$389.70
[B] = Wksh 1,
V35 / Wksh 1,
V33
Risk Adjustment
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
$27.28
G-6
[C] = Wksh 1,
V37 / Wksh 1,
V33
Transitional
Reinsurance
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
$4.92
[D] = [A]+[B]+[C]
Market Adjusted
Index Rate
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
$421.90
9/9/2014
State of Missouri
[E]
Plan
Name
1401A
1402A
1403A
1404A
1405A
1406A
1407A
1408A
1409A
1410A
1411A
1412A
1413A
1414A
1415A
1416A
1417A
1418A
1501A
1502A
1503A
1504A
1505A
1506A
1507A
1508A
1509A
1510A
1511A
1512A
1513A
MO-201501
HIOS Plan ID
64701MO0030001
64701MO0030002
64701MO0030003
64701MO0030004
64701MO0030005
64701MO0030006
64701MO0030007
64701MO0030008
64701MO0030009
64701MO0030010
64701MO0030011
64701MO0030012
64701MO0030013
64701MO0030014
64701MO0030015
64701MO0030016
64701MO0030017
64701MO0030018
64701MO0030091
64701MO0030092
64701MO0030093
64701MO0030094
64701MO0030095
64701MO0030096
64701MO0030097
64701MO0030098
64701MO0030099
64701MO0030100
64701MO0030101
64701MO0030102
64701MO0030103
Metallic
Tier
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Gold
Silver
Silver
Bronze
Bronze
Gold
Gold
Gold
Silver
Silver
Silver
Silver
Member
Months
37
35
35
34
34
24
37
35
35
35
34
35
34
34
24
37
35
34
34
35
34
34
24
24
35
35
35
34
34
34
34
Cost Sharing
and Actuarial
Value
Adjustment
0.886
0.783
0.789
0.689
0.685
0.607
0.891
0.795
0.790
0.787
0.717
0.792
0.689
0.689
0.589
0.888
0.781
0.684
0.687
0.796
0.710
0.700
0.612
0.613
0.818
0.811
0.787
0.718
0.705
0.691
0.717
[F]
Network
Adjustment
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
0.973
[G]
Utilization
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
G-7
[H] = 1 / (1 Total
Expense %)
Expense
Load
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
[I]
Tobacco
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[J]
Benefits in
Addition to
EHB
1.005
1.000
0.999
0.998
0.992
1.021
0.999
1.011
1.003
1.003
0.972
1.005
1.000
1.000
0.985
0.994
1.009
1.004
0.990
1.030
1.003
1.006
1.013
0.946
1.002
1.001
0.996
0.981
0.966
1.007
1.004
[K]
Catastrophic
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[L]=[E]x[F]x[G]x
[H]x[I]x[J]x[K]
Pricing AV
1.099
0.967
0.973
0.849
0.839
0.765
1.099
0.993
0.978
0.975
0.860
0.983
0.851
0.851
0.716
1.090
0.973
0.848
0.840
1.012
0.880
0.870
0.765
0.716
1.012
1.002
0.968
0.870
0.841
0.859
0.889
9/9/2014
State of Missouri
[E]
Plan
Name
1514A
1515A
1516A
1401B
1402B
1403B
1404B
1405B
1406B
1407B
1408B
1409B
1410B
1411B
1412B
1413B
1414B
1415B
1416B
1417B
1418B
1501B
1502B
1503B
1504B
1505B
1506B
1507B
1508B
1509B
1510B
MO-201501
HIOS Plan ID
64701MO0030104
64701MO0030105
64701MO0030106
64701MO0030019
64701MO0030020
64701MO0030021
64701MO0030022
64701MO0030023
64701MO0030024
64701MO0030025
64701MO0030026
64701MO0030027
64701MO0030028
64701MO0030029
64701MO0030030
64701MO0030031
64701MO0030032
64701MO0030033
64701MO0030034
64701MO0030035
64701MO0030036
64701MO0030107
64701MO0030108
64701MO0030109
64701MO0030110
64701MO0030111
64701MO0030112
64701MO0030113
64701MO0030114
64701MO0030115
64701MO0030116
Metallic
Tier
Bronze
Bronze
Bronze
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Gold
Silver
Silver
Bronze
Bronze
Gold
Gold
Gold
Silver
Member
Months
24
24
24
37
35
35
34
34
24
37
35
35
35
34
35
34
34
24
37
35
34
34
35
34
34
24
24
35
35
35
34
Cost Sharing
and Actuarial
Value
Adjustment
0.592
0.582
0.616
0.886
0.783
0.789
0.689
0.685
0.607
0.891
0.795
0.790
0.787
0.717
0.792
0.689
0.689
0.589
0.888
0.781
0.684
0.687
0.796
0.710
0.700
0.612
0.613
0.818
0.811
0.787
0.718
[F]
Network
Adjustment
0.973
0.973
0.973
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
1.072
[G]
Utilization
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
G-8
[H] = 1 / (1 Total
Expense %)
Expense
Load
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
[I]
Tobacco
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[J]
Benefits in
Addition to
EHB
0.980
0.997
0.988
1.005
1.000
0.999
0.998
0.992
1.021
0.999
1.011
1.003
1.003
0.972
1.005
1.000
1.000
0.985
0.994
1.009
1.004
0.990
1.030
1.003
1.006
1.013
0.946
1.002
1.001
0.996
0.981
[K]
Catastrophic
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[L]=[E]x[F]x[G]x
[H]x[I]x[J]x[K]
Pricing AV
0.716
0.716
0.751
1.212
1.066
1.073
0.936
0.925
0.844
1.212
1.094
1.078
1.075
0.948
1.084
0.938
0.938
0.789
1.201
1.073
0.935
0.926
1.116
0.970
0.959
0.844
0.789
1.116
1.105
1.067
0.959
9/9/2014
State of Missouri
[E]
Plan
Name
1511B
1512B
1513B
1514B
1515B
1516B
1401C
1402C
1403C
1404C
1405C
1406C
1407C
1408C
1409C
1410C
1411C
1412C
1413C
1414C
1415C
1416C
1417C
1418C
1501C
1502C
1503C
1504C
1505C
1506C
1507C
MO-201501
HIOS Plan ID
64701MO0030117
64701MO0030118
64701MO0030119
64701MO0030120
64701MO0030121
64701MO0030122
64701MO0030037
64701MO0030038
64701MO0030039
64701MO0030040
64701MO0030041
64701MO0030042
64701MO0030043
64701MO0030044
64701MO0030045
64701MO0030046
64701MO0030047
64701MO0030048
64701MO0030049
64701MO0030050
64701MO0030051
64701MO0030052
64701MO0030053
64701MO0030054
64701MO0030123
64701MO0030124
64701MO0030125
64701MO0030126
64701MO0030127
64701MO0030128
64701MO0030129
Metallic
Tier
Silver
Silver
Silver
Bronze
Bronze
Bronze
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Gold
Silver
Silver
Bronze
Bronze
Gold
Member
Months
34
34
34
24
24
24
443
423
423
409
409
285
443
423
423
423
409
423
409
409
285
443
423
409
409
423
409
409
285
285
423
Cost Sharing
and Actuarial
Value
Adjustment
0.705
0.691
0.717
0.592
0.582
0.616
0.886
0.783
0.789
0.689
0.685
0.607
0.891
0.795
0.790
0.787
0.717
0.792
0.689
0.689
0.589
0.888
0.781
0.684
0.687
0.796
0.710
0.700
0.612
0.613
0.818
[F]
Network
Adjustment
1.072
1.072
1.072
1.072
1.072
1.072
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
[G]
Utilization
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
G-9
[H] = 1 / (1 Total
Expense %)
Expense
Load
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
[I]
Tobacco
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[J]
Benefits in
Addition to
EHB
0.966
1.007
1.004
0.980
0.997
0.988
1.005
1.000
0.999
0.998
0.992
1.021
0.999
1.011
1.003
1.003
0.972
1.005
1.000
1.000
0.985
0.994
1.009
1.004
0.990
1.030
1.003
1.006
1.013
0.946
1.002
[K]
Catastrophic
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[L]=[E]x[F]x[G]x
[H]x[I]x[J]x[K]
Pricing AV
0.927
0.947
0.980
0.789
0.789
0.828
1.127
0.991
0.998
0.871
0.861
0.785
1.127
1.018
1.003
1.000
0.882
1.008
0.872
0.873
0.734
1.118
0.998
0.870
0.861
1.038
0.902
0.892
0.785
0.734
1.038
9/9/2014
State of Missouri
[E]
Plan
Name
1508C
1509C
1510C
1511C
1512C
1513C
1514C
1515C
1516C
1401D
1402D
1403D
1404D
1405D
1406D
1407D
1408D
1409D
1410D
1411D
1412D
1413D
1414D
1415D
1416D
1417D
1418D
1501D
1502D
1503D
1504D
MO-201501
HIOS Plan ID
64701MO0030130
64701MO0030131
64701MO0030132
64701MO0030133
64701MO0030134
64701MO0030135
64701MO0030136
64701MO0030137
64701MO0030138
64701MO0030055
64701MO0030056
64701MO0030057
64701MO0030058
64701MO0030059
64701MO0030060
64701MO0030061
64701MO0030062
64701MO0030063
64701MO0030064
64701MO0030065
64701MO0030066
64701MO0030067
64701MO0030068
64701MO0030069
64701MO0030070
64701MO0030071
64701MO0030072
64701MO0030139
64701MO0030140
64701MO0030141
64701MO0030142
Metallic
Tier
Gold
Gold
Silver
Silver
Silver
Silver
Bronze
Bronze
Bronze
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Gold
Silver
Silver
Member
Months
423
423
409
409
409
409
285
285
285
74
70
70
68
68
47
74
70
70
70
68
70
68
68
47
74
70
68
68
70
68
68
Cost Sharing
and Actuarial
Value
Adjustment
0.811
0.787
0.718
0.705
0.691
0.717
0.592
0.582
0.616
0.886
0.783
0.789
0.689
0.685
0.607
0.891
0.795
0.790
0.787
0.717
0.792
0.689
0.689
0.589
0.888
0.781
0.684
0.687
0.796
0.710
0.700
[F]
Network
Adjustment
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
[G]
Utilization
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
G-10
[H] = 1 / (1 Total
Expense %)
Expense
Load
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
[I]
Tobacco
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[J]
Benefits in
Addition to
EHB
1.001
0.996
0.981
0.966
1.007
1.004
0.980
0.997
0.988
1.005
1.000
0.999
0.998
0.992
1.021
0.999
1.011
1.003
1.003
0.972
1.005
1.000
1.000
0.985
0.994
1.009
1.004
0.990
1.030
1.003
1.006
[K]
Catastrophic
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[L]=[E]x[F]x[G]x
[H]x[I]x[J]x[K]
Pricing AV
1.028
0.993
0.892
0.862
0.881
0.912
0.734
0.734
0.771
1.127
0.991
0.998
0.871
0.861
0.785
1.127
1.018
1.003
1.000
0.882
1.008
0.872
0.873
0.734
1.118
0.998
0.870
0.861
1.038
0.902
0.892
9/9/2014
State of Missouri
[E]
Plan
Name
1505D
1506D
1507D
1508D
1509D
1510D
1511D
1512D
1513D
1514D
1515D
1516D
1401E
1402E
1403E
1404E
1405E
1406E
1407E
1408E
1409E
1410E
1411E
1412E
1413E
1414E
1415E
1416E
1417E
1418E
1501E
MO-201501
HIOS Plan ID
64701MO0030143
64701MO0030144
64701MO0030145
64701MO0030146
64701MO0030147
64701MO0030148
64701MO0030149
64701MO0030150
64701MO0030151
64701MO0030152
64701MO0030153
64701MO0030154
64701MO0030073
64701MO0030074
64701MO0030075
64701MO0030076
64701MO0030077
64701MO0030078
64701MO0030079
64701MO0030080
64701MO0030081
64701MO0030082
64701MO0030083
64701MO0030084
64701MO0030085
64701MO0030086
64701MO0030087
64701MO0030088
64701MO0030089
64701MO0030090
64701MO0030155
Metallic
Tier
Bronze
Bronze
Gold
Gold
Gold
Silver
Silver
Silver
Silver
Bronze
Bronze
Bronze
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Member
Months
47
47
70
70
70
68
68
68
68
47
47
47
148
141
141
136
136
95
148
141
141
141
136
141
136
136
95
148
141
136
136
Cost Sharing
and Actuarial
Value
Adjustment
0.612
0.613
0.818
0.811
0.787
0.718
0.705
0.691
0.717
0.592
0.582
0.616
0.886
0.783
0.789
0.689
0.685
0.607
0.891
0.795
0.790
0.787
0.717
0.792
0.689
0.689
0.589
0.888
0.781
0.684
0.687
[F]
Network
Adjustment
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
[G]
Utilization
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
G-11
[H] = 1 / (1 Total
Expense %)
Expense
Load
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
[I]
Tobacco
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[J]
Benefits in
Addition to
EHB
1.013
0.946
1.002
1.001
0.996
0.981
0.966
1.007
1.004
0.980
0.997
0.988
1.005
1.000
0.999
0.998
0.992
1.021
0.999
1.011
1.003
1.003
0.972
1.005
1.000
1.000
0.985
0.994
1.009
1.004
0.990
[K]
Catastrophic
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[L]=[E]x[F]x[G]x
[H]x[I]x[J]x[K]
Pricing AV
0.785
0.734
1.038
1.028
0.993
0.892
0.862
0.881
0.912
0.734
0.734
0.771
1.127
0.991
0.998
0.871
0.861
0.785
1.127
1.018
1.003
1.000
0.882
1.008
0.872
0.873
0.734
1.118
0.998
0.870
0.861
9/9/2014
State of Missouri
[E]
Plan
Name
1502E
1503E
1504E
1505E
1506E
1507E
1508E
1509E
1510E
1511E
1512E
1513E
1514E
1515E
1516E
MO-201501
HIOS Plan ID
64701MO0030156
64701MO0030157
64701MO0030158
64701MO0030159
64701MO0030160
64701MO0030161
64701MO0030162
64701MO0030163
64701MO0030164
64701MO0030165
64701MO0030166
64701MO0030167
64701MO0030168
64701MO0030169
64701MO0030170
Metallic
Tier
Gold
Silver
Silver
Bronze
Bronze
Gold
Gold
Gold
Silver
Silver
Silver
Silver
Bronze
Bronze
Bronze
Member
Months
141
136
136
95
95
141
141
141
136
136
136
136
95
95
95
Cost Sharing
and Actuarial
Value
Adjustment
0.796
0.710
0.700
0.612
0.613
0.818
0.811
0.787
0.718
0.705
0.691
0.717
0.592
0.582
0.616
[F]
Network
Adjustment
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
0.998
[G]
Utilization
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
G-12
[H] = 1 / (1 Total
Expense %)
Expense
Load
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
1.269
[I]
Tobacco
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[J]
Benefits in
Addition to
EHB
1.030
1.003
1.006
1.013
0.946
1.002
1.001
0.996
0.981
0.966
1.007
1.004
0.980
0.997
0.988
[K]
Catastrophic
Adjustment
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[L]=[E]x[F]x[G]x
[H]x[I]x[J]x[K]
Pricing AV
1.038
0.902
0.892
0.785
0.734
1.038
1.028
0.993
0.892
0.862
0.881
0.912
0.734
0.734
0.771
9/9/2014
State of Missouri
Avg Age Fx =
1.403
[D]
Plan
Name
1401A
1402A
1403A
1404A
1405A
1406A
1407A
1408A
1409A
1410A
1411A
1412A
1413A
1414A
1415A
1416A
1417A
1418A
1501A
1502A
1503A
1504A
1505A
1506A
1507A
1508A
1509A
1510A
1511A
1512A
1513A
HIOS Plan ID
64701MO0030001
64701MO0030002
64701MO0030003
64701MO0030004
64701MO0030005
64701MO0030006
64701MO0030007
64701MO0030008
64701MO0030009
64701MO0030010
64701MO0030011
64701MO0030012
64701MO0030013
64701MO0030014
64701MO0030015
64701MO0030016
64701MO0030017
64701MO0030018
64701MO0030091
64701MO0030092
64701MO0030093
64701MO0030094
64701MO0030095
64701MO0030096
64701MO0030097
64701MO0030098
64701MO0030099
64701MO0030100
64701MO0030101
64701MO0030102
64701MO0030103
MO-201501
Metallic
Tier
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Gold
Silver
Silver
Bronze
Bronze
Gold
Gold
Gold
Silver
Silver
Silver
Silver
Member
Months
37
35
35
34
34
24
37
35
35
35
34
35
34
34
24
37
35
34
34
35
34
34
24
24
35
35
35
34
34
34
34
[L]
[M]=[D]x[L]
Market
Adjusted
Plan
Index
Adjusted
Rate Pricing AV Index Rate
$421.90
1.099
$463.79
$421.90
0.967
$407.80
$421.90
0.973
$410.62
$421.90
0.849
$358.19
$421.90
0.839
$354.07
$421.90
0.765
$322.94
$421.90
1.099
$463.79
$421.90
0.993
$418.75
$421.90
0.978
$412.59
$421.90
0.975
$411.25
$421.90
0.860
$362.94
$421.90
0.983
$414.69
$421.90
0.851
$358.86
$421.90
0.851
$358.95
$421.90
0.716
$302.10
$421.90
1.090
$459.73
$421.90
0.973
$410.62
$421.90
0.848
$357.77
$421.90
0.840
$354.19
$421.90
1.012
$427.11
$421.90
0.880
$371.09
$421.90
0.870
$366.96
$421.90
0.765
$322.94
$421.90
0.716
$302.10
$421.90
1.012
$426.88
$421.90
1.002
$422.82
$421.90
0.968
$408.46
$421.90
0.870
$366.96
$421.90
0.841
$354.73
$421.90
0.859
$362.31
$421.90
0.889
$375.02
[N]
Age Factor
Calibration
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
G-13
[O]
Geographic
Calibration
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[P]=[M]x{N]x[O]
Consumer
Adjusted
Premium Rates
$330.64
$290.72
$292.74
$255.36
$252.42
$230.22
$330.64
$298.53
$294.14
$293.19
$258.74
$295.63
$255.84
$255.90
$215.37
$327.74
$292.74
$255.06
$252.50
$304.49
$264.56
$261.61
$230.22
$215.37
$304.33
$301.43
$291.20
$261.61
$252.89
$258.29
$267.36
9/9/2014
State of Missouri
Avg Age Fx =
1.403
[D]
Plan
Name
1514A
1515A
1516A
1401B
1402B
1403B
1404B
1405B
1406B
1407B
1408B
1409B
1410B
1411B
1412B
1413B
1414B
1415B
1416B
1417B
1418B
1501B
1502B
1503B
1504B
1505B
1506B
1507B
1508B
1509B
1510B
HIOS Plan ID
64701MO0030104
64701MO0030105
64701MO0030106
64701MO0030019
64701MO0030020
64701MO0030021
64701MO0030022
64701MO0030023
64701MO0030024
64701MO0030025
64701MO0030026
64701MO0030027
64701MO0030028
64701MO0030029
64701MO0030030
64701MO0030031
64701MO0030032
64701MO0030033
64701MO0030034
64701MO0030035
64701MO0030036
64701MO0030107
64701MO0030108
64701MO0030109
64701MO0030110
64701MO0030111
64701MO0030112
64701MO0030113
64701MO0030114
64701MO0030115
64701MO0030116
MO-201501
Metallic
Tier
Bronze
Bronze
Bronze
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Gold
Silver
Silver
Bronze
Bronze
Gold
Gold
Gold
Silver
Member
Months
24
24
24
37
35
35
34
34
24
37
35
35
35
34
35
34
34
24
37
35
34
34
35
34
34
24
24
35
35
35
34
[L]
[M]=[D]x[L]
Market
Adjusted
Plan
Index
Adjusted
$421.90
0.716
$302.10
$421.90
0.716
$302.10
$421.90
0.751
$317.02
$421.90
1.212
$511.36
$421.90
1.066
$449.62
$421.90
1.073
$452.73
$421.90
0.936
$394.93
$421.90
0.925
$390.39
$421.90
0.844
$356.06
$421.90
1.212
$511.36
$421.90
1.094
$461.70
$421.90
1.078
$454.90
$421.90
1.075
$453.43
$421.90
0.948
$400.16
$421.90
1.084
$457.22
$421.90
0.938
$395.67
$421.90
0.938
$395.76
$421.90
0.789
$333.09
$421.90
1.201
$506.88
$421.90
1.073
$452.73
$421.90
0.935
$394.46
$421.90
0.926
$390.51
$421.90
1.116
$470.91
$421.90
0.970
$409.15
$421.90
0.959
$404.60
$421.90
0.844
$356.06
$421.90
0.789
$333.09
$421.90
1.116
$470.66
$421.90
1.105
$466.18
$421.90
1.067
$450.35
$421.90
0.959
$404.60
[N]
Age Factor
Calibration
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
G-14
[O]
Geographic
Calibration
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[P]=[M]x{N]x[O]
Consumer
Adjusted
Premium Rates
$215.37
$215.37
$226.01
$364.56
$320.54
$322.76
$281.55
$278.31
$253.84
$364.56
$329.15
$324.31
$323.26
$285.28
$325.96
$282.08
$282.15
$237.46
$361.36
$322.76
$281.22
$278.40
$335.72
$291.69
$288.44
$253.84
$237.46
$335.54
$332.35
$321.06
$288.44
9/9/2014
State of Missouri
Avg Age Fx =
1.403
[D]
Plan
Name
1511B
1512B
1513B
1514B
1515B
1516B
1401C
1402C
1403C
1404C
1405C
1406C
1407C
1408C
1409C
1410C
1411C
1412C
1413C
1414C
1415C
1416C
1417C
1418C
1501C
1502C
1503C
1504C
1505C
1506C
1507C
HIOS Plan ID
64701MO0030117
64701MO0030118
64701MO0030119
64701MO0030120
64701MO0030121
64701MO0030122
64701MO0030037
64701MO0030038
64701MO0030039
64701MO0030040
64701MO0030041
64701MO0030042
64701MO0030043
64701MO0030044
64701MO0030045
64701MO0030046
64701MO0030047
64701MO0030048
64701MO0030049
64701MO0030050
64701MO0030051
64701MO0030052
64701MO0030053
64701MO0030054
64701MO0030123
64701MO0030124
64701MO0030125
64701MO0030126
64701MO0030127
64701MO0030128
64701MO0030129
MO-201501
Metallic
Tier
Silver
Silver
Silver
Bronze
Bronze
Bronze
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Gold
Silver
Silver
Bronze
Bronze
Gold
Member
Months
34
34
34
24
24
24
443
423
423
409
409
285
443
423
423
423
409
423
409
409
285
443
423
409
409
423
409
409
285
285
423
[L]
[M]=[D]x[L]
Market
Adjusted
Plan
Index
Adjusted
$421.90
0.927
$391.11
$421.90
0.947
$399.47
$421.90
0.980
$413.49
$421.90
0.789
$333.09
$421.90
0.789
$333.09
$421.90
0.828
$349.53
$421.90
1.127
$475.69
$421.90
0.991
$418.25
$421.90
0.998
$421.15
$421.90
0.871
$367.38
$421.90
0.861
$363.15
$421.90
0.785
$331.22
$421.90
1.127
$475.69
$421.90
1.018
$429.49
$421.90
1.003
$423.16
$421.90
1.000
$421.80
$421.90
0.882
$372.25
$421.90
1.008
$425.32
$421.90
0.872
$368.06
$421.90
0.873
$368.15
$421.90
0.734
$309.85
$421.90
1.118
$471.51
$421.90
0.998
$421.15
$421.90
0.870
$366.94
$421.90
0.861
$363.27
$421.90
1.038
$438.06
$421.90
0.902
$380.61
$421.90
0.892
$376.37
$421.90
0.785
$331.22
$421.90
0.734
$309.85
$421.90
1.038
$437.83
[N]
Age Factor
Calibration
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
G-15
[O]
Geographic
Calibration
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[P]=[M]x{N]x[O]
Consumer
Adjusted
Premium Rates
$278.83
$284.79
$294.78
$237.46
$237.46
$249.19
$339.12
$298.18
$300.24
$261.91
$258.90
$236.13
$339.12
$306.19
$301.68
$300.70
$265.38
$303.21
$262.40
$262.46
$220.89
$336.15
$300.24
$261.60
$258.98
$312.30
$271.34
$268.32
$236.13
$220.89
$312.13
9/9/2014
State of Missouri
Avg Age Fx =
1.403
[D]
Plan
Name
1508C
1509C
1510C
1511C
1512C
1513C
1514C
1515C
1516C
1401D
1402D
1403D
1404D
1405D
1406D
1407D
1408D
1409D
1410D
1411D
1412D
1413D
1414D
1415D
1416D
1417D
1418D
1501D
1502D
1503D
1504D
HIOS Plan ID
64701MO0030130
64701MO0030131
64701MO0030132
64701MO0030133
64701MO0030134
64701MO0030135
64701MO0030136
64701MO0030137
64701MO0030138
64701MO0030055
64701MO0030056
64701MO0030057
64701MO0030058
64701MO0030059
64701MO0030060
64701MO0030061
64701MO0030062
64701MO0030063
64701MO0030064
64701MO0030065
64701MO0030066
64701MO0030067
64701MO0030068
64701MO0030069
64701MO0030070
64701MO0030071
64701MO0030072
64701MO0030139
64701MO0030140
64701MO0030141
64701MO0030142
MO-201501
Metallic
Tier
Gold
Gold
Silver
Silver
Silver
Silver
Bronze
Bronze
Bronze
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Gold
Silver
Silver
Member
Months
423
423
409
409
409
409
285
285
285
74
70
70
68
68
47
74
70
70
70
68
70
68
68
47
74
70
68
68
70
68
68
[L]
[M]=[D]x[L]
Market
Adjusted
Plan
Index
Adjusted
$421.90
1.028
$433.66
$421.90
0.993
$418.93
$421.90
0.892
$376.37
$421.90
0.862
$363.82
$421.90
0.881
$371.60
$421.90
0.912
$384.64
$421.90
0.734
$309.85
$421.90
0.734
$309.85
$421.90
0.771
$325.15
$421.90
1.127
$475.69
$421.90
0.991
$418.25
$421.90
0.998
$421.15
$421.90
0.871
$367.38
$421.90
0.861
$363.15
$421.90
0.785
$331.22
$421.90
1.127
$475.69
$421.90
1.018
$429.49
$421.90
1.003
$423.16
$421.90
1.000
$421.80
$421.90
0.882
$372.25
$421.90
1.008
$425.32
$421.90
0.872
$368.06
$421.90
0.873
$368.15
$421.90
0.734
$309.85
$421.90
1.118
$471.51
$421.90
0.998
$421.15
$421.90
0.870
$366.94
$421.90
0.861
$363.27
$421.90
1.038
$438.06
$421.90
0.902
$380.61
$421.90
0.892
$376.37
[N]
Age Factor
Calibration
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
G-16
[O]
Geographic
Calibration
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[P]=[M]x{N]x[O]
Consumer
Adjusted
Premium Rates
$309.16
$298.66
$268.32
$259.38
$264.92
$274.21
$220.89
$220.89
$231.80
$339.12
$298.18
$300.24
$261.91
$258.90
$236.13
$339.12
$306.19
$301.68
$300.70
$265.38
$303.21
$262.40
$262.46
$220.89
$336.15
$300.24
$261.60
$258.98
$312.30
$271.34
$268.32
9/9/2014
State of Missouri
Avg Age Fx =
1.403
[D]
Plan
Name
1505D
1506D
1507D
1508D
1509D
1510D
1511D
1512D
1513D
1514D
1515D
1516D
1401E
1402E
1403E
1404E
1405E
1406E
1407E
1408E
1409E
1410E
1411E
1412E
1413E
1414E
1415E
1416E
1417E
1418E
1501E
HIOS Plan ID
64701MO0030143
64701MO0030144
64701MO0030145
64701MO0030146
64701MO0030147
64701MO0030148
64701MO0030149
64701MO0030150
64701MO0030151
64701MO0030152
64701MO0030153
64701MO0030154
64701MO0030073
64701MO0030074
64701MO0030075
64701MO0030076
64701MO0030077
64701MO0030078
64701MO0030079
64701MO0030080
64701MO0030081
64701MO0030082
64701MO0030083
64701MO0030084
64701MO0030085
64701MO0030086
64701MO0030087
64701MO0030088
64701MO0030089
64701MO0030090
64701MO0030155
MO-201501
Metallic
Tier
Bronze
Bronze
Gold
Gold
Gold
Silver
Silver
Silver
Silver
Bronze
Bronze
Bronze
Platinum
Gold
Gold
Silver
Silver
Bronze
Platinum
Gold
Gold
Gold
Silver
Gold
Silver
Silver
Bronze
Platinum
Gold
Silver
Silver
Member
Months
47
47
70
70
70
68
68
68
68
47
47
47
148
141
141
136
136
95
148
141
141
141
136
141
136
136
95
148
141
136
136
[L]
[M]=[D]x[L]
Market
Adjusted
Plan
Index
Adjusted
$421.90
0.785
$331.22
$421.90
0.734
$309.85
$421.90
1.038
$437.83
$421.90
1.028
$433.66
$421.90
0.993
$418.93
$421.90
0.892
$376.37
$421.90
0.862
$363.82
$421.90
0.881
$371.60
$421.90
0.912
$384.64
$421.90
0.734
$309.85
$421.90
0.734
$309.85
$421.90
0.771
$325.15
$421.90
1.127
$475.69
$421.90
0.991
$418.25
$421.90
0.998
$421.15
$421.90
0.871
$367.38
$421.90
0.861
$363.15
$421.90
0.785
$331.22
$421.90
1.127
$475.69
$421.90
1.018
$429.49
$421.90
1.003
$423.16
$421.90
1.000
$421.80
$421.90
0.882
$372.25
$421.90
1.008
$425.32
$421.90
0.872
$368.06
$421.90
0.873
$368.15
$421.90
0.734
$309.85
$421.90
1.118
$471.51
$421.90
0.998
$421.15
$421.90
0.870
$366.94
$421.90
0.861
$363.27
[N]
Age Factor
Calibration
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
G-17
[O]
Geographic
Calibration
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[P]=[M]x{N]x[O]
Consumer
Adjusted
Premium Rates
$236.13
$220.89
$312.13
$309.16
$298.66
$268.32
$259.38
$264.92
$274.21
$220.89
$220.89
$231.80
$339.12
$298.18
$300.24
$261.91
$258.90
$236.13
$339.12
$306.19
$301.68
$300.70
$265.38
$303.21
$262.40
$262.46
$220.89
$336.15
$300.24
$261.60
$258.98
9/9/2014
State of Missouri
Avg Age Fx =
1.403
[D]
Plan
Name
1502E
1503E
1504E
1505E
1506E
1507E
1508E
1509E
1510E
1511E
1512E
1513E
1514E
1515E
1516E
HIOS Plan ID
64701MO0030156
64701MO0030157
64701MO0030158
64701MO0030159
64701MO0030160
64701MO0030161
64701MO0030162
64701MO0030163
64701MO0030164
64701MO0030165
64701MO0030166
64701MO0030167
64701MO0030168
64701MO0030169
64701MO0030170
MO-201501
Metallic
Tier
Gold
Silver
Silver
Bronze
Bronze
Gold
Gold
Gold
Silver
Silver
Silver
Silver
Bronze
Bronze
Bronze
Member
Months
141
136
136
95
95
141
141
141
136
136
136
136
95
95
95
[L]
[M]=[D]x[L]
Market
Adjusted
Plan
Index
Adjusted
$421.90
1.038
$438.06
$421.90
0.902
$380.61
$421.90
0.892
$376.37
$421.90
0.785
$331.22
$421.90
0.734
$309.85
$421.90
1.038
$437.83
$421.90
1.028
$433.66
$421.90
0.993
$418.93
$421.90
0.892
$376.37
$421.90
0.862
$363.82
$421.90
0.881
$371.60
$421.90
0.912
$384.64
$421.90
0.734
$309.85
$421.90
0.734
$309.85
$421.90
0.771
$325.15
[N]
Age Factor
Calibration
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
0.713
G-18
[O]
Geographic
Calibration
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
[P]=[M]x{N]x[O]
Consumer
Adjusted
Premium Rates
$312.30
$271.34
$268.32
$236.13
$220.89
$312.13
$309.16
$298.66
$268.32
$259.38
$264.92
$274.21
$220.89
$220.89
$231.80
9/9/2014
State of Missouri
Attachment H: Policy Experience

Nationwide and Missouri-Specific Experience Based on Claims Paid Through April 30, 2014:
Nationwide Experience
Year
2009
2010
2011
2012
2013
TOTAL
Member Months
976,990
845,707
825,739
758,030
771,377
4,177,843
Earned Premium
Incurred Claims
294,816,105
274,471,082
281,969,847
267,696,377
286,438,516
1,405,391,928
244,866,274
227,516,970
233,037,877
219,264,567
221,951,189
1,146,636,877
Earned Premium
Incurred Claims
Actual
Loss Ratio
83.1%
82.9%
82.6%
81.9%
77.5%
81.6%
Missouri-Specific Experience
Year
2009
2010
2011
2012
2013
TOTAL
Member Months
62,653
61,558
59,790
62,132
73,783
319,916
18,454,259
18,978,120
19,440,039
19,631,497
24,720,653
101,224,567
Actual
Loss Ratio
11,594,890
12,867,134
13,024,393
15,050,679
17,966,666
70,503,762
62.8%
67.8%
67.0%
76.7%
72.7%
69.7%
Note: represents actual loss ratio experience for the time period specified. The pricing expereince takes into account trend,
changes to network discounts and network availability, demographic differences and plan variations.
MO - 201501
H-1
07/10/2014
ActuarialMemorandum
StateofMissouri
AttachmentJGeographicCalibration
RatingArea
1
2
3
4
5
6
7
8
9
10
WeightedAvg
MO201501
AreaFactor
0.980
0.980
1.040
1.040
0.960
1.000
0.900
0.960
1.010
1.000
0.999
Assumed
Distribution
5.8%
6.4%
16.4%
3.5%
7.4%
35.0%
0.1%
9.2%
6.8%
9.3%
J1
8/11/2014

2015 Federated Small Group Rate Filing PDF

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ActuarialMemorandum

Variance of Capped Allowed Charges PMPM

State - Specific Member Months during the Experience Period

NationwideAllowed Charges PMPM 100% - Credibility Factor

Digitally signed by Scott D Haglund

Attachment A - Consumer Adjusted Index Rate

Sample Rate Calculation

Geo Rating Area 4 x

Maximum of 3 children under 21 yrs.

Network A is available statewide

Network B is available in Rating Areas 1, 4, 5, and 7 - 9

Network C is avaliable in Rating Areas 2 and 4 - 10

Network D is avaliable in Rating Areas 3, 4, and 7 - 9

Network E is avaliable in Rating Areas 1, 3 - 5, 7, and 8

Attachment A - Plan Designs

Metal Level Network

OON - Family OOP

Attachment A - Plan Designs

Metal Level Network

OON - Family OOP

Attachment A - Plan Designs

Metal Level Network

OON - Family OOP

Attachment A - Plan Designs

Metal Level Network

OON - Family OOP

Attachment A - Plan Designs

Metal Level Network

OON - Family OOP

Attachment A - Area Definitions

Attachment B - Trend Impact on Index Rate

April Effective July Effective October

Attachment C - Credibility Adjustment Factor

Step 1: Adjust State-Specific Experience for Large Claims

Claim & Benefit

Step 2: Determine Credibility of State-Specific Experience

F = Member Months needed for full credibility is equal to 1,082 * [1 + (Variance)/(Mean^2)].

Step 3: Credibility-Adjust State-Specific Experience

Attachment D - MLR Projection, Federally Prescribed

Projection Period Incurred Claims

$6,969,383 [A] URRT Worksheet 1, Line 38

Projected MLR before Credibility Adjustment:

80.6% [E] = [A] / [D]

Projected Credibility Adjustment:

82.7% [G] = [E] + [F]

Projected Incurred Claims / Projected Premium (non MLR)

visits per year

days per year

visits per year

cardiac rehab 36 sessions; OT 20 visits, PT

exam per year

Covered in bundled dental policy

Covered in bundled dental policy

Covered in bundled dental policy

Natl Paid Claims

HIOS Plan ID Metallic Tier

Member Projected Index

HIOS Plan ID Metallic Tier

Member Projected Index

HIOS Plan ID Metallic Tier

Member Projected Index

HIOS Plan ID Metallic Tier