Filing at a Glance - DFS Portal...Filing at a Glance Company: HealthPlus HP, LLC Product Name:...

Filing at a Glance

Company: HealthPlus HP, LLCProduct Name: IndividualState: New YorkTOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)Sub-TOI: HOrg02I.005D Individual - HMOFiling Type: 2020 Prior Approval ACA RatesDate Submitted: 05/22/2019SERFF Tr Num: AWLP-131950100SERFF Status: Pending Industry ResponseState Tr Num: 2019050298State Status: CP-xx-CRCo Tr Num: INDIVIDUAL

ImplementationDate Requested:

01/01/2020

Author(s):

Reviewer(s):Disposition Date:Disposition Status:Implementation Date:

State Filing Description:

SERFF Tracking #: AWLP-131950100 State Tracking #: 2019050298 Company Tracking #: INDIVIDUAL

State: New York Filing Company: HealthPlus HP, LLCTOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005D Individual - HMOProduct Name: IndividualProject Name/Number: Individual/

PDF Pipeline for SERFF Tracking Number AWLP-131950100 Generated 05/31/2019 08:09 AM

General Information

Company and Contact

Filing Fees

State Specific

Project Name: Individual Status of Filing in Domicile:Project Number: Date Approved in Domicile:Requested Filing Mode: Review & Approval Domicile Status Comments:Explanation for Combination/Other: Market Type: IndividualSubmission Type: New Submission Individual Market Type: IndividualOverall Rate Impact: Filing Status Changed: 05/30/2019

State Status Changed: 05/30/2019Deemer Date: Created By: Submitted By: Corresponding Filing Tracking Number:

PPACA: Not PPACA-Related

PPACA Notes: nullInclude Exchange Intentions: No

Filing Description:Individual – HMO

Form Filing: AWLP-131946692

Filing Contact Information

Filing Company InformationHealthPlus HP, LLC9 Pine StNew York, NY 10005(212) 476-1000 ext. [Phone]

CoCode: 16574Group Code: 671Group Name: Anthem, Inc.FEIN Number: 13-3865627

State of Domicile: New YorkCompany Type:Accident/HealthState ID Number:

Fee Required? No

Retaliatory? No

Fee Explanation:

1. Is a parallel filing being submitted for another issuing entity of the same parent organization? Yes/No (If Yes, enter nameof other entity, submission date, and SERFF Tracking Number of the parallel file.): No2. Does this filing contain a dental, vision or health insurance policy or contract that uses a network of health care providers?(If Yes, enter the PNDS Network ID number and name. If the network has not been filed in PNDS, it must be filed within 60days of approval.): 0128, Empire BCBS HealthPlus / HealthPlus HP, LLC. - Essential Plan3. : n/a




4. Type of filing? Enter Form and Rate, Form only, Rate only (Form only should be used ONLY when the filing only containsan application, advertisement, administrative form, or is a group prefiling notification, out-of-state, or a report filing. Formsubmissions with no proposed rate impact are considered form and rate filings and require an actuarial memorandum.): RateOnly5. Is this a Rate only filing? Yes/No [If Yes, enter one: Commission/Fee Schedule, DBL Loss Ratio Monitoring, ExperienceFiling Monitoring, Experience Rating Formula, Medicare Supplement Annual Filing (other than rate adjustment), RateAdjustment, or Other with brief explanation).]: Yes - Prior Approval Rate Adjustment6. Does this submission contain a form subject to Regulation 123 (i.e., the certificate is deemed delivered in New York State)?Yes/No (If Yes, provide a full explanation in the Filing Description field.): No7. Did this insurer prefile group coverage for this group under Section 52.32 prior to this filing? Yes/No (If Yes, enter thestate tracking number assigned and the effective date of coverage.): Yes, AWLP-1319384578. Does this submission contain any form which is subject to review by the Life Bureau, the Property Bureau or both? Yes/No(If Yes, identify the forms, the Bureau, the date submitted, and the SERFF file number.): No9. Does this filing contain forms that replace any other previously approved forms? Yes/No (If Yes, identify the formnumbers, the file number, and the date of approval of the forms being replaced in the Filing Description field.): No




Rate Information Rate data applies to filing.

Filing Method:Rate Change Type: IncreaseOverall Percentage of Last Rate Revision: %Effective Date of Last Rate Revision:Filing Method of Last Filing:SERFF Tracking Number of Last Filing:

Company Rate Information

CompanyName:

CompanyRateChange:

Overall %IndicatedChange:

Overall %RateImpact:

WrittenPremiumChange forthis Program:

Number of PolicyHolders Affectedfor this Program:

WrittenPremium forthis Program:

Maximum %Change(where req'd):

Minimum %Change(where req'd):

HealthPlus HP, LLC Increase % % % %




Rate Review Detail COMPANY:Company Name: HealthPlus HP, LLCHHS Issuer Id: 41046

PRODUCTS:

Product Name HIOS Product ID HIOS Submission ID Number of CoveredLives

HealthPlus 22167

Trend Factors:

FORMS:New Policy Forms: AWLP-131946692Affected Forms:Other Affected Forms:

REQUESTED RATE CHANGE INFORMATION:Change Period: AnnualMember Months: 266,004Benefit Change: IncreasePercent Change Requested: Min: -2.97 Max: 8.71 Avg: 2.36

PRIOR RATE:Total Earned Premium: 202,212,010.20Total Incurred Claims: 174,468,522.40Annual $: Min: 205.50 Max: 1,179.40 Avg: 760.18

REQUESTED RATE:Projected Earned Premium: 206,986,455.80Projected Incurred Claims: 178,587,914.10Annual $: Min: 211.94 Max: 1,165.47 Avg: 778.13




Rate/Rule Schedule

ItemNo.

ScheduleItemStatus

Document NameAffected Form Numbers(Separated with commas) Rate Action Rate Action Information Attachments

1 Rate Manual Pages New Other manual pages -IND.pdf, Other manualpages - IND.xlsx, INDRate Manual.pdf, INDRate Manual.xlsx,




HealthPlus HP, LLC May 2019

Rate Manual

HealthPlus HP, LLC

Table of Contents

I. Direct Payment Products Open for Enrollment

HealthPlus HMO – On/Off Exchange I-1

II. Appendix

Commission ScheduleBroker CommissionSample Rate CalculationOpt-In RiderArea FactorsContract Type FactorsVariation FactorsIndex


Rate Manual

HealthPlus HP, LLCIndividual

On Exchange PlansEffective Date: January 1, 2020

In-Network Coverage Only2 22 120 125 28 26 32 191 188 60 141 138 168 78

PCP Specialist

CATASTROPHICHealthPlus Gatekeeper X, Catastrophic

$8,150/$16,300 3 @ $0 before Ded. $0 0% $8,150/

$16,300 $0 0% 0% 0% 0% 0% 0% 0% 0%

BRONZE

HealthPlus Gatekeeper X for HSA, Bronze, Dep 25

$5,500/$11,000 50% 50% 50% $6,550/

$13,100

Tier 1 - $10Tier 2 - $35Tier 3 - $70

50% 50% 50% 50% 50% 50% 50%* 50%

SILVER

HealthPlus Gatekeeper X, Silver, Dep 25

$1,300/$2,600 $30 $50 N/A $7,900/

$15,800

Tier 1 - $10Tier 2 - $35

Tier 3 - $70; No Deductible$1,500 per admit $250 $70 $150 per use

$1,500 per admit, $100 for prenatal & delivery physician

$1,500 per admit, PCP copay for outpt $30 per visit* $50 per visit

GOLD

HealthPlus Gatekeeper X, Gold, Dep 25

$600/$1,200 $25 $40 N/A $4,000/

$8,000

Tier 1 - $10Tier 2 - $35



$1,000 per admit, PCP copay for outpatient $30 per visit* $40 per visit

PLATINUM

HealthPlus Gatekeeper X, Platinum, Dep 25 $0/$0 $15 $35 N/A $2,000/

$4,000

Tier 1 - $10Tier 2 - $30

Tier 3 - $60; No Deductible$500 per admit $100 $55 $100 per use

$500 per admit, $100 for prenatal & delivery physician

$500 per admit, PCP copay for outpatient $25 per visit* $35 per visit

*limited to 60 visits per condition per plan year

All Plans include Pediatric Vision and the following:

Pediatric DentalPreventive Dental Care

Routine Dental Care Orthodontia

Catastrophic 0% after deductible 0% after deductible 0% after deductible

Bronze 50% after deductible 50% after deductible 50% after deductible

Silver$30 copay after

deductible$30 copay after

deductible$30 copay after deductible

Gold$25 copay after



Platinum$15 copay after



Rehab & Habilitative DiagnosticsMental Health & Substance Abuse

Retail PharmacyPreferred / Non Preferred

Inpatient Hospital

Emergency Room(Facility)

UrgentCare

Outpt Hospital(Facility)

Maternity & Newborn Care

$15 copay after deductible

Plan NameDeductible

Single/ Family

Office VisitNetwork

Coins OOP Max

Single/ Family

Major Dental Care (Oral Surgery, Endodontics, Periodontics and

Prosthodontics)

0% after deductible

50% after deductible




Rate Manual


Off Exchange PlansEffective Date: January 1, 2020

In-Network Coverage Only2 22 120 125 28 26 32 191 188 60 141 138 168 78

PCP SpecialistCATASTROPHICHealthPlus Gatekeeper, Catastrophic

$8,150/$16,300 3 @ $0 before Ded. $0 0% $8,150/

$16,300 $0 0% 0% 0% 0% 0% 0% 0% 0%

BRONZEHealthPlus Gatekeeper for HSA, Bronze, Dep 25

$5,500/$11,000 50% 50% 50% $6,550/

$13,100

Tier 1 - $10Tier 2 - $35Tier 3 - $70

50% 50% 50% 50% 50% 50% 50%* 50%

SILVER

HealthPlus Gatekeeper, Silver, Dep 25

$1,300/$2,600 $30 $50 N/A $7,900/

$15,800

Tier 1 - $10Tier 2 - $35



$1,500 per admit, PCP copay for outpt $30 per visit* $50 per visit

GOLD

HealthPlus Gatekeeper, Gold, Dep 25

$600/$1,200 $25 $40 N/A $4,000/

$8,000

Tier 1 - $10Tier 2 - $35



$1,000 per admit, PCP copay for outpatient $30 per visit* $40 per visit

PLATINUM

HealthPlus Gatekeeper, Platinum, Dep 25 $0/$0 $15 $35 N/A $2,000/

$4,000

Tier 1 - $10Tier 2 - $30

Tier 3 - $60; No Deductible$500 per admit $100 $55 $100 per use

$500 per admit, $100 for prenatal & delivery physician

$500 per admit, PCP copay for outpatient $25 per visit* $35 per visit

*limited to 60 visits per condition per plan year

All Plans include Pediatric Vision and the following:

Pediatric Dental Preventive Dental Care

Routine Dental Care

Orthodontia

Catastrophic 0% after deductible 0% after deductible 0% after deductible

Bronze 50% after deductible 50% after deductible 50% after deductible

Silver$30 copay after



Gold$25 copay after



Platinum$15 copay after



Plan NameDeductible

Single/ FamilyOffice Visit Network

Coins OOP Max

Single/ Family DiagnosticsInpatient Hospital

Emergency Room(Facility)

UrgentCare

Outpt Hospital

Maternity & Newborn Care

Mental Health & Substance Abuse

50% after deductible




Rehab & HabilitativeRetail PharmacyPreferred / Non Preferred

Major Dental Care (Oral Surgery, Endodontics, Periodontics and

0% after deductible


Commission Schedule for HMO PlansEffective Date: January 1, 2020

Product Contract Per Member Per Month (PMPM)HMO New $0HMO Renewal $0

Notes:1.

2.

This schedule applies to commissions paid on all new and renewal Individual commissionable products on or after the Effective Date.

This schedule applies to both on and off exchange products in the individual market.

Rate Manual



Plan: HealthPlus Gatekeeper X, Gold, ST, INN, Pediatric Dental, Dep 29Rating Region: Albany (Region 1)Expected Loss Ratio: 86.5%

IndividualHusband/

WifeParent/

Child(ren) FamilyBase Rates: $990.63 $1,981.26 $1,684.07 $2,823.30

TOTAL $990.63 $1,981.26 $1,684.07 $2,823.30

Rate Manual


On Exchange Sample Rate CalculationEffective Date: January 1, 2020


Plan: HealthPlus Gatekeeper, Gold, ST, INN, Pediatric Dental, Dep 29, SNFRating Region: Albany (Region 1)Expected Loss Ratio: 86.5%

IndividualHusband/

WifeParent/

Child(ren) FamilyBase Rates: $991.28 $1,982.56 $1,685.18 $2,825.15

TOTAL $991.28 $1,982.56 $1,685.18 $2,825.15

Rate Manual


Off Exchange Sample Rate CalculationEffective Date: January 1, 2020


Rating Area Description Area Factor Counties Included

Albany 0.8881Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga,

Schenectady, Schoharie, Warren, and Washington

Long Island 0.9189 Nassau and Suffolk

Mid-Hudson 1.0475 Delaware, Dutchess, Orange, Putnam, Sullivan, and Ulster

New York City 1.0442 Bronx, Kings, New York, Queens, Richmond, Rockland, and Westchester

Upstate 1.4725 Clinton and Essex

Rate Manual


Effective Date: January 1, 2020Area Factors


Rate Manual


Contract Type FactorsEffective Date: January 1, 2020

Contract Type Factor

Single 1.000

Single + Spouse 2.000

Single + Child(ren) 1.700

Child Only 0.412

Family 2.850


Rate Manual

HealthPlus HP, L HealthPlus HP, LLCIndividual

VariationsEffective Date: January 1, 2020

Variation FactorRemove Family Planning Coverage 1.000Remove Domestic Partner Coverage 1.000


HIOS ID Form Number Page

41046NY0010010 NY_ONHIX_ST_HP_GK_CAT (1/20) I-141046NY0010009 NY_ONHIX_ST_HP_GK_CAT (1/20) I-141046NY0010002 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010001 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010012 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010011 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010020 NY_ONHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0010019 NY_ONHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0010003 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010014 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010013 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010022 NY_ONHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0010021 NY_ONHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0010004 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010024 NY_ONHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0010006 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010005 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010016 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010023 NY_ONHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0010015 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010008 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010007 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010018 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010017 NY_ONHIX_ST_HP_GK (1/20) I-141046NY0010026 NY_ONHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0010025 NY_ONHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020008 NY_ OFFHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020007 NY_ OFFHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020010 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020009 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020011 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020012 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020006 NY_ OFFHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020005 NY_ OFFHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020014 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020015 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020016 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020013 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020002 NY_ OFFHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020001 NY_ OFFHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020018 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020017 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020020 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020019 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020004 NY_ OFFHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020003 NY_ OFFHIX_ST_HP_GK_CHILD ONLY (1/20) I-141046NY0020022 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020021 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020024 NY_OFFHIX_ST_HP_GK (1/20) I-141046NY0020023 NY_OFFHIX_ST_HP_GK (1/20) I-1


Effective Date: January 1, 2020

Rate Manual

Index

Index HIOS Plan Name Individual

Husband/

Wife

Parent/

Child(ren) Family

1 HealthPlus Gatekeeper X, Catastrophic, ST, INN, Pediatric Dental $243.67 $487.34 $414.24 $694.46

2 HealthPlus Gatekeeper X, for HSA, Bronze, ST, INN, Pediatric Dental, Dep 25 $562.41 $1,124.82 $956.10 $1,602.87


4 HealthPlus Gatekeeper X, Gold, ST, INN, Pediatric Dental, Dep 25 $951.42 $1,902.84 $1,617.41 $2,711.55


6 HealthPlus Gatekeeper X, Platinum, ST, INN, Pediatric Dental, Dep 25 $1,157.11 $2,314.22 $1,967.09 $3,297.76


8 HealthPlus Gatekeeper X, Silver, ST, INN, Pediatric Dental, Dep 25 $760.78 $1,521.56 $1,293.33 $2,168.22


10 HealthPlus Gatekeeper for HSA, Bronze, ST, INN, Pediatric Dental, Dep 25, SNF $562.82 $1,125.64 $956.79 $1,604.04


12 HealthPlus Gatekeeper, Gold, ST, INN, Pediatric Dental, Dep 25, SNF $952.16 $1,904.32 $1,618.67 $2,713.66


14 HealthPlus Gatekeeper, Platinum, ST, INN, Pediatric Dental, Dep 25, SNF $1,157.93 $2,315.86 $1,968.48 $3,300.10


16 HealthPlus Gatekeeper, Silver, ST, INN, Pediatric Dental, Dep 25, SNF $761.35 $1,522.70 $1,294.30 $2,169.85


Index HIOS Plan Name

Child Only

(1 Child)

Child Only

(2 Children)

Child Only

(3+ Children)

18 HealthPlus Gatekeeper X, for HSA, Bronze, ST, INN, Pediatric Dental, Child Only $230.66 $461.32 $691.98

19 HealthPlus Gatekeeper X, Gold Child Only, ST, INN, Pediatric Dental $393.81 $787.62 $1,181.43

20 HealthPlus Gatekeeper X, Platinum Child Only, ST, INN, Pediatric Dental $480.10 $960.20 $1,440.30

21 HealthPlus Gatekeeper X, Silver Child Only, ST, INN, Pediatric Dental $314.10 $628.20 $942.30

22 HealthPlus Gatekeeper for HSA, Bronze, ST, INN, Pediatric Dental, Child Only, SNF $230.82 $461.64 $692.46

23 HealthPlus Gatekeeper, Gold Child Only, ST, INN, Pediatric Dental, SNF $394.14 $788.28 $1,182.42

24 HealthPlus Gatekeeper, Platinum Child Only, ST, INN, Pediatric Dental, SNF $480.43 $960.86 $1,441.29

25 HealthPlus Gatekeeper, Silver Child Only, ST, INN, Pediatric Dental, SNF $314.35 $628.70 $943.05

Form Number(s): NY_ONHIX_ST_HP_GK(1/20), NY_OFFHIX_ST_HP_GK(1/20), NY_ONHIX_ST_HP_GK_CHILD(1/20),

NY_OFFHIX_ST_HP_GK_CHILD(1/20), NY_OFFHIX_ST_HP_GK_CAT(1/20), NY_ONHIX_ST_HP_GK_CAT(1/20)

Albany (Region 1)

Individual

Calendar Year 2020

Rate Manual

HealthPlus HP, LLC

HealthPlus HP, LLC I‐1 May 2019


Husband/

Wife

Parent/

Child(ren) Family



3 HealthPlus Gatekeeper X, for HSA, Bronze, ST, INN, Pediatric Dental, Dep 29 $606.07 $1,212.14 $1,030.32 $1,727.30


5 HealthPlus Gatekeeper X, Gold, ST, INN, Pediatric Dental, Dep 29 $1,024.98 $2,049.96 $1,742.47 $2,921.19






11 HealthPlus Gatekeeper for HSA, Bronze, ST, INN, Pediatric Dental, Dep 29, SNF $606.49 $1,212.98 $1,031.03 $1,728.50


13 HealthPlus Gatekeeper, Gold, ST, INN, Pediatric Dental, Dep 29, SNF $1,025.66 $2,051.32 $1,743.62 $2,923.13






Child Only

(1 Child)

Child Only

(2 Children)

Child Only

(3+ Children)



20 HealthPlus Gatekeeper X, Platinum Child Only, ST, INN, Pediatric Dental $496.75 $993.50 $1,490.25

21 HealthPlus Gatekeeper X, Silver Child Only, ST, INN, Pediatric Dental $325.00 $650.00 $975.00



24 HealthPlus Gatekeeper, Platinum Child Only, ST, INN, Pediatric Dental, SNF $497.09 $994.18 $1,491.27

25 HealthPlus Gatekeeper, Silver Child Only, ST, INN, Pediatric Dental, SNF $325.25 $650.50 $975.75



Long Island (Region 8)

Individual

Calendar Year 2020

Rate Manual

HealthPlus HP, LLC



Husband/

Wife

Parent/

Child(ren) Family



















Child Only

(1 Child)

Child Only

(2 Children)

Child Only

(3+ Children)



20 HealthPlus Gatekeeper X, Platinum Child Only, ST, INN, Pediatric Dental $566.28 $1,132.56 $1,698.84

21 HealthPlus Gatekeeper X, Silver Child Only, ST, INN, Pediatric Dental $370.48 $740.96 $1,111.44



24 HealthPlus Gatekeeper, Platinum Child Only, ST, INN, Pediatric Dental, SNF $566.66 $1,133.32 $1,699.98

25 HealthPlus Gatekeeper, Silver Child Only, ST, INN, Pediatric Dental, SNF $370.77 $741.54 $1,112.31



Mid‐Hudson (Region 3)

Individual

Calendar Year 2020

Rate Manual

HealthPlus HP, LLC



Husband/

Wife

Parent/

Child(ren) Family



















Child Only

(1 Child)

Child Only

(2 Children)

Child Only

(3+ Children)




21 HealthPlus Gatekeeper X, Silver Child Only, ST, INN, Pediatric Dental $369.31 $738.62 $1,107.93




25 HealthPlus Gatekeeper, Silver Child Only, ST, INN, Pediatric Dental, SNF $369.60 $739.20 $1,108.80



New York City (Region 4)

Individual

Calendar Year 2020

Rate Manual

HealthPlus HP, LLC



Husband/

Wife

Parent/

Child(ren) Family

1 HealthPlus Gatekeeper X, Catastrophic, ST, INN, Pediatric Dental $404.02 $808.04 $686.83 $1,151.46







8 HealthPlus Gatekeeper X, Silver, ST, INN, Pediatric Dental, Dep 25 $1,261.40 $2,522.80 $2,144.38 $3,594.99

9 HealthPlus Gatekeeper X, Silver, ST, INN, Pediatric Dental, Dep 29 $1,313.45 $2,626.90 $2,232.87 $3,743.33







16 HealthPlus Gatekeeper, Silver, ST, INN, Pediatric Dental, Dep 25, SNF $1,262.35 $2,524.70 $2,146.00 $3,597.70

17 HealthPlus Gatekeeper, Silver, ST, INN, Pediatric Dental, Dep 29, SNF $1,314.26 $2,628.52 $2,234.24 $3,745.64


Child Only

(1 Child)

Child Only

(2 Children)

Child Only

(3+ Children)

18 HealthPlus Gatekeeper X, for HSA, Bronze, ST, INN, Pediatric Dental, Child Only $382.44 $764.88 $1,147.32

19 HealthPlus Gatekeeper X, Gold Child Only, ST, INN, Pediatric Dental $652.95 $1,305.90 $1,958.85


21 HealthPlus Gatekeeper X, Silver Child Only, ST, INN, Pediatric Dental $520.80 $1,041.60 $1,562.40

22 HealthPlus Gatekeeper for HSA, Bronze, ST, INN, Pediatric Dental, Child Only, SNF $382.71 $765.42 $1,148.13

23 HealthPlus Gatekeeper, Gold Child Only, ST, INN, Pediatric Dental, SNF $653.49 $1,306.98 $1,960.47


25 HealthPlus Gatekeeper, Silver Child Only, ST, INN, Pediatric Dental, SNF $521.20 $1,042.40 $1,563.60



Upstate (Region 7)

Individual

Calendar Year 2020

Rate Manual

HealthPlus HP, LLC


Supporting Document Schedules Satisfied - Item: Actuarial Value CalculationsComments:

Attachment(s):

20190503NYDownstate (BCBS)41046INDOnAVCalculatorScreenshots.pdf20190503NYUpstate (BC)41046INDOnAVCalculatorScreenshots.pdf20190503NYDownstate (BCBS)41046INDCATOnUniqueAVJustificationsSet1.pdf20190503NYUpstate (BC)41046INDCATOnUniqueAVJustificationsSet1.pdfAV Snapshots- 2020 Standard Plans.pdf

Item Status:Status Date:

Satisfied - Item: Exhibit 13b: Narrative SummaryComments:Attachment(s): Individual Narrative 2020.pdfItem Status:Status Date:

Satisfied - Item: Exhibit 13c: Average Premium DetailsComments:

Attachment(s): 2020_exh13C_IND.pdf2020_exh13C_IND.xlsm


Satisfied - Item: Exhibit 14: Summary of Requested Percentage ChangesComments:

Attachment(s): 2020_exh14_IND.pdf2020_exh14_IND.xlsm


Satisfied - Item: Exhibit 15a: Product Discontinuance CertificationComments: n/aAttachment(s):Item Status:Status Date:




Satisfied - Item: Exhibit 15b: MHPAEA Compliance CertificationComments: n/a- only standard productsAttachment(s):Item Status:Status Date:

Satisfied - Item: Exhibit 16: Summary of Policy Form & Product ChangesComments:



Satisfied - Item: Exhibit 17: Claims ExperienceComments:

Attachment(s): 2020_exh17_04022019 - IND.pdf2020_exh17_04022019 - IND.xlsm


Satisfied - Item: Exhibit 18: Index Rate/Plan-Design Level AdjustmentComments:



Satisfied - Item: Exhibit 19: Summary of Average Claim Trend and Admin Expenses and Profit MarginComments:



Satisfied - Item: Exhibit 23: Summary of Requested 2020 Premium RatesComments:






Satisfied - Item: Final Notice of Proposed Rate AdjustmentComments: The final notice is pending review by the DFS.Attachment(s):Item Status:Status Date:

Satisfied - Item: Initial Notice of Proposed Rate AdjustmentComments:Attachment(s): 06093_NYMENMUB_NY_LTR_NOF_051019_FINAL.PDFItem Status:Status Date:

Satisfied - Item: Redacted Documents for Web PostingComments:

Attachment(s):

checklist_filing_2020_IND_Redacted.pdf2020 Actuarial Memorandum_NY IND - Federal_Redacted.pdf2020_exh11_IND_Redacted.pdf2020_exh13A_IND_Redacted.pdf2020_exh21A_IND_Redacted.pdf2020_exh21B_IND_Redacted.pdf2020_exh22_04022019 - IND_Redacted.pdf2020 Actuarial Memorandum_NY IND - State_Redacted.pdf


Satisfied - Item: Unified Rate Review TemplateComments:

Attachment(s): URRT-NY-IND-41046-1Q20 -Submission-2019-05-13-19.pdfURRT-NY-IND-41046-1Q20 -Submission-2019-05-13-19.xlsm





User Inputs for Plan Parameters

Use Integrated Medical and Drug Deductible?

Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Tiered Network Plan?

Apply Skilled Nursing Facility Copay per Day?

Use Separate MOOP for Medical and Drug Spending?

Indicate if Plan Meets CSR or Expanded Bronze AV Standard?

Desired Metal Tier Bronze

Medical Drug Combined Medical Drug Combined

Deductible ($) $8,150.00

Coinsurance (%, Insurer's Cost Share) 100.00%

MOOP ($) $8,150.00

MOOP if Separate ($)

Click Here for Important Instructions Tier 1 Tier 2

Type of BenefitSubject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical

Emergency Room Services

All Inpatient Hospital Services (inc. MH/SUD)

Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays)

Specialist Visit

Mental/Behavioral Health and Substance Use Disorder Outpatient Services 100%

Imaging (CT/PET Scans, MRIs) 100%

Speech Therapy 100%

Occupational and Physical Therapy 100%

Preventive Care/Screening/Immunization 100% $0.00

Laboratory Outpatient and Professional Services 100%

X-rays and Diagnostic Imaging

Skilled Nursing Facility

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Outpatient Surgery Physician/Surgical Services

Drugs

Generics

Preferred Brand Drugs

Non-Preferred Brand Drugs

Specialty Drugs (i.e. high-cost)

Options for Additional Benefit Design Limits: Plan Description:

Set a Maximum on Specialty Rx Coinsurance Payments? HIOS Issuer ID: 41046

Specialty Rx Coinsurance Maximum: HIOS Product ID: 41046NY001

Set a Maximum Number of Days for Charging an IP Copay? HIOS Plan ID: 41046NY0010010-01

# Days (1-10):

Begin Primary Care Cost-Sharing After a Set Number of Visits?

# Visits (1-10):

Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?

# Copays (1-10): 3

Output

Status/Error Messages: Expanded Bronze Standard (56% to 65%), Calculation Successful.

Actuarial Value: 61.79%

Metal Tier: Bronze

Additional Notes:

Calculation Time: 0.0469 seconds

Final 2020 AV Calculator

$3,487.28

$5,643.59

Copay applies only after deductible?

Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design

Tier 1 Tier 2

HSA/HRA Options Tiered Network Option

Annual Contribution Amount:1st Tier Utilization:

2nd Tier Utilization:

All

All

All

All

All

All

All

All

All All

All All

User Inputs for Plan Parameters

Use Integrated Medical and Drug Deductible?

Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Tiered Network Plan?

Apply Skilled Nursing Facility Copay per Day?

Use Separate MOOP for Medical and Drug Spending?

Indicate if Plan Meets CSR or Expanded Bronze AV Standard?

Desired Metal Tier Bronze

Medical Drug Combined Medical Drug Combined

Deductible ($) $8,150.00

Coinsurance (%, Insurer's Cost Share) 100.00%

MOOP ($) $8,150.00

MOOP if Separate ($)

Click Here for Important Instructions Tier 1 Tier 2

Type of BenefitSubject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical

Emergency Room Services

All Inpatient Hospital Services (inc. MH/SUD)

Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays)

Specialist Visit

Mental/Behavioral Health and Substance Use Disorder Outpatient Services 100%

Imaging (CT/PET Scans, MRIs) 100%

Speech Therapy 100%

Occupational and Physical Therapy 100%

Preventive Care/Screening/Immunization 100% $0.00

Laboratory Outpatient and Professional Services 100%

X-rays and Diagnostic Imaging

Skilled Nursing Facility

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Outpatient Surgery Physician/Surgical Services

Drugs

Generics

Preferred Brand Drugs

Non-Preferred Brand Drugs

Specialty Drugs (i.e. high-cost)

Options for Additional Benefit Design Limits: Plan Description:

Set a Maximum on Specialty Rx Coinsurance Payments? HIOS Issuer ID: 41046

Specialty Rx Coinsurance Maximum: HIOS Product ID: 41046NY001

Set a Maximum Number of Days for Charging an IP Copay? HIOS Plan ID: 41046NY0010009-01

# Days (1-10):

Begin Primary Care Cost-Sharing After a Set Number of Visits?

# Visits (1-10):

Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?

# Copays (1-10): 3

Output

Status/Error Messages: Expanded Bronze Standard (56% to 65%), Calculation Successful.

Actuarial Value: 61.79%

Metal Tier: Bronze

Additional Notes:

Calculation Time: 0.0312 seconds

Final 2020 AV Calculator

$3,487.28

$5,643.59

Copay applies only after deductible?

Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design

Tier 1 Tier 2

HSA/HRA Options Tiered Network Option

Annual Contribution Amount:1st Tier Utilization:

2nd Tier Utilization:

All

All

All

All

All

All

All

All

All All

All All

Please fill in the following information.

HIOS Issuer ID:

HIOS Product IDs:

Applicable HIOS Plan IDs (Standard Component):41046NY0010010-01

Reasons the plan design is unique (benefits that are not compatible with the parameters of the AV Calculator and the materiality of those benefits):

5

7

Plan designs apply a member copay prior to deductible for a limited number of office visits with remaining office visits subject to deductible and coinsurance. The limited visits

at a copayment are combined across multiple benefit categories. In addition to primary care visits, limits apply across specialist visits, outpatient mental/behavioral health and

substance use disorder office services, speech therapy, and/or physical and occupational therapies. The limited copays prior to deductible functionality in the AV Calculator is

only applicable to the primary care visits benefit category.

The AV Calculator has five service types (mental/behavioral health and substance use disorder outpatient services; imaging; speech therapy; occupational therapy and physical

therapy; and laboratory outpatient and professional services) that include services also classified as outpatient-facility and outpatient-professional. If special cost-sharing

provisions are indicated for outpatient - facility and/or outpatient - professional claims and no special cost sharing is indicated for the service type, then the service(s) including

both an outpatient-facility and outpatient-professional component will be split into their component parts and the outpatient facility and outpatient-professional relevant cost

sharing applied when calculating the plan AV.

41046

41046NY001

Unique Plan Design Supporting

Documentation and Justification

Version 1 Page 1 of 5

Acceptable alternate method used per 156.135(b)(2) or 156.135(b)(3):

5

7

Per 156.135(b)(2), a weighted average of the member cost shares for visits subject to copays and the member cost shares for visits subject to plan deductible and coinsurance

are calculated and converted to an effective coinsurance.

Per 156.135(b)(2), the AV Calculator (AVC) user guide notes that service specific cost-sharing features are always primary to any input in the outpatient facility fee and/or

outpatient surgical physician/surgical service fields. Therefore, a small adjustment factor is multiplied by the specific service coinsurance, only when the coinsurance equals

the plan coinsurance as loaded into cell D11 and H11 of the AVC. While not materially impacting the plan's AV, this adjustment prevents the outpatient facility fee and

outpatient surgery physician/surgical service fee override methodology from being invoked which Anthem believes is not appropriate for our benefit plans.


Confirmation that only in-network cost sharing, including multitier networks, was considered: Yes

Description of the standardized plan population data used: Used AV Calculator population data.

If the method described in 156.135(b)(2) was used, a description of how the benefits weremodified to fit the parameters of the AV Calculator:

5

7

Using proprietary claims data, weightings were determined to model the number of office visit services that would be subject to a limited copayment or the plan deductible

and coinsurance. Due to the combined structure of the office visit services, across several categories, a redistribution of the weighting factors were modeled based on

frequency of service statistics from a nationally known consulting firm. The final weightings were used to convert the plan member cost shares to an effective coinsurance for

each service category subject to the limited visits at a copayment.

Method Used: For each of the five specific service categories, the final coinsurance is checked to see if it equals the plan coinsurance. If the service specific coinsurance equals

the plan coinsurance then a factor of 0.9999 is multiplied by the service specific coinsurance and the result is loaded into the coinsurance row of the specific service category

of the AV Calculator. An example of the calculation for speech therapy services where the service specific coinsurance is 90% and the plan coinsurance is 90%. The adjusted

speech therapy coinsurance is calculated as (90% * 0.9999 = 89.99%). The 89.99% adjusted speech therapy coinsurance is loaded into cell D24 and cell H44, where applicable,

of the AV calculator.


If the method described in 156.135(b)(3) was used, a description of the data and methodused to develop the adjustments: This method was not used.


Certification Language:

The development of the actuarial value is based on one of the acceptable alternative methods outlined in 156.135(b)(2) or 156.135(b)(3) for those benefits that deviate substantially from theparameters of the AV Calculator and have a material impact on the AV

The analysis was (i) conducted by a member of the American Academy of Actuaries; (ii) performed in accordance with generally accepted actuarial principles and methodologies;

Actuary signature:

Actuary Printed Name:

Date: May 3, 2019


Please fill in the following information.

HIOS Issuer ID:

HIOS Product IDs:

Applicable HIOS Plan IDs (Standard Component):41046NY0010009-01

Reasons the plan design is unique (benefits that are not compatible with the parameters of the AV Calculator and the materiality of those benefits):

5

7

Plan designs apply a member copay prior to deductible for a limited number of office visits with remaining office visits subject to deductible and coinsurance. The limited

visits at a copayment are combined across multiple benefit categories. In addition to primary care visits, limits apply across specialist visits, outpatient mental/behavioral

health and substance use disorder office services, speech therapy, and/or physical and occupational therapies. The limited copays prior to deductible functionality in the AV

Calculator is only applicable to the primary care visits benefit category.

The AV Calculator has five service types (mental/behavioral health and substance use disorder outpatient services; imaging; speech therapy; occupational therapy and

physical therapy; and laboratory outpatient and professional services) that include services also classified as outpatient-facility and outpatient-professional. If special cost-

sharing provisions are indicated for outpatient - facility and/or outpatient - professional claims and no special cost sharing is indicated for the service type, then the service(s)

including both an outpatient-facility and outpatient-professional component will be split into their component parts and the outpatient facility and outpatient-professional

relevant cost sharing applied when calculating the plan AV.

41046

41046NY001

Unique Plan Design Supporting

Documentation and Justification


Acceptable alternate method used per 156.135(b)(2) or 156.135(b)(3):

5

7

Per 156.135(b)(2), a weighted average of the member cost shares for visits subject to copays and the member cost shares for visits subject to plan deductible and

coinsurance are calculated and converted to an effective coinsurance.

Per 156.135(b)(2), the AV Calculator (AVC) user guide notes that service specific cost-sharing features are always primary to any input in the outpatient facility fee and/or

outpatient surgical physician/surgical service fields. Therefore, a small adjustment factor is multiplied by the specific service coinsurance, only when the coinsurance equals

the plan coinsurance as loaded into cell D11 and H11 of the AVC. While not materially impacting the plan's AV, this adjustment prevents the outpatient facility fee and

outpatient surgery physician/surgical service fee override methodology from being invoked which Anthem believes is not appropriate for our benefit plans.


Confirmation that only in-network cost sharing, including multitier networks, was considered: Yes

Description of the standardized plan population data used: Used AV Calculator population data.

If the method described in 156.135(b)(2) was used, a description of how the benefits weremodified to fit the parameters of the AV Calculator:

5

7

Using proprietary claims data, weightings were determined to model the number of office visit services that would be subject to a limited copayment or the plan deductible

and coinsurance. Due to the combined structure of the office visit services, across several categories, a redistribution of the weighting factors were modeled based on

frequency of service statistics from a nationally known consulting firm. The final weightings were used to convert the plan member cost shares to an effective coinsurance

for each service category subject to the limited visits at a copayment.

Method Used: For each of the five specific service categories, the final coinsurance is checked to see if it equals the plan coinsurance. If the service specific coinsurance

equals the plan coinsurance then a factor of 0.9999 is multiplied by the service specific coinsurance and the result is loaded into the coinsurance row of the specific service

category of the AV Calculator. An example of the calculation for speech therapy services where the service specific coinsurance is 90% and the plan coinsurance is 90%. The

adjusted speech therapy coinsurance is calculated as (90% * 0.9999 = 89.99%). The 89.99% adjusted speech therapy coinsurance is loaded into cell D24 and cell H44, where

applicable, of the AV calculator.


If the method described in 156.135(b)(3) was used, a description of the data and methodused to develop the adjustments: This method was not used.


Certification Language:

The development of the actuarial value is based on one of the acceptable alternative methods outlined in 156.135(b)(2) or 156.135(b)(3) for those benefits that deviate substantially from theparameters of the AV Calculator and have a material impact on the AV

The analysis was (i) conducted by a member of the American Academy of Actuaries; (ii) performed in accordance with generally accepted actuarial principles and methodologies;

Actuary signature:

Actuary Printed Name:

Date: May 3, 2019


***** 2020 STANDARD PLATINUM PLAN (04/22/2019) *****

***** 2020 STANDARD PLATINUM PLAN (04/22/2019) *****

***** 2020 STANDARD GOLD PLAN (04/22/2019) *****

***** 2020 STANDARD GOLD PLAN (04/22/2019) *****

***** 2020 STANDARD SILVER PLAN (04/22/2019) *****

***** 2020 STANDARD SILVER PLAN (04/22/2019) *****

***** 2020 STANDARD SILVER CSR 200‐250% FPL PLAN (04/22/2019) *****


*****��2020�STANDARD�BRONZE�PLAN�WITH�NO�COST�SHARING�ON�THE�FIRST�3�PCP�VISITS�(04/22/2019)��*****

*****��2020�STANDARD�BRONZE�PLAN�WITH�NO�COST�SHARING�ON�THE�FIRST�3�PCP�VISITS�(04/22/2019)��*****

Actuarial Value AV Calculation 64.79% Mental Health Parity for first 3 PCP visits with no cost sharing 0.21% Adjusted actuarial value 65.00%

***** 2020 STANDARD BRONZE HSA COMPLIANT PLAN (04/22/2019) *****

***** 2020 STANDARD BRONZE HSA COMPLIANT PLAN (04/22/2019) *****

EXHIBIT 13b: NARRATIVE SUMMARY

Company Name: HealthPlus HP, LLC

NAIC Code: 16574 SERFF Tracking #: AWLP-131950100 Market Segment: Individual

14 Wall Street, New York, NY 10005, Telephone (212) 476 1000 REQUEST OF:

HEALTHPLUS HP, LLC

TO:

THE DEPARTMENT OF FINANCIAL SERVICES of the STATE OF NEW YORK

FOR APPROVAL OF COMMUNITY RATE CHANGES

Updated May 13, 2019

Exhibit 13b – Narrative Summary Last Updated: 5/13/2019

NARRATIVE SUMMARY [DFS and policyholder – for public posting]

I. OVERVIEW HealthPlus, LLC (HealthPlus) has made an application to the Superintendent of Financial Services to adjust premium rates for health insurance available to individual customers. These individual customers and their covered dependents are combined, by long standing New York law, in what is known as a community rated pool. All members enrolled in the pool plans are guaranteed issuance of coverage and each contract holder is charged the same premium rate as any other contract holder for the health insurance product they select regardless of health status, age, sex, or other demographic factors other than the region of the State where they reside and family type. All medical, hospital, pharmacy, and other non-specialty covered care and necessary administrative costs are combined, by law, in the pool in order to determine appropriate premium rates. These premium rates must support sufficient, sustainable reserves for both current and future coverage costs related to community pool products on a stand-alone basis. Current approved rates for Empire’s community pool products are in need of an increase to account for the rising costs incurred as provider charges continue to rise and utilization of services increases. The products specifically impacted by rate increases at this time are individual policies sold by Empire HealthChoice Assurance, Inc., (Empire’s insurance company; NAIC code number 55093). These products are not expected to continue to be offered in 2020. Rather, HealthPlus will offer new HMO individual policies starting in 2020 to take their place. The rate adjustments impact both on-exchange and off-exchange policies. The actual rate increases requested are provided below. HealthPlus's proposed rates are subject to review and approval by the New York Department of Financial Services (“the Department”), with the determination by the Department supported by sound actuarial assumptions and methods. The rates currently in effect were filed with the Department on May 14, 2018 (SERFF number: AWLP-131478945) and subsequently approved by the Department for use in 2019. The 2020 rate applications will be submitted to the Department for approval on May 13, 2019 and the approved rates will be communicated to the impacted parties upon completion of the Department's review and are scheduled to be effective on January 1, 2020. HealthPlus is required by New York State law to develop rates that are actuarially sound, assume at least 82% of premium revenue will be spent on health care costs, cover all claim costs, and also contribute to claims reserves. The percent of premium attributable to claims is essentially how much of the premium dollar is used to pay claims and is referred to as the Medical Loss Ratio (MLR). The actual MLR may vary over time based on changes in the amounts charged by hospitals, physicians, and other providers, as well as the increase in health care trend or inflation and health care utilization by our members. With the proposed rate adjustments, HealthPlus's overall MLR is expected to remain well above the 82% minimum allowable ratio. In the event HealthPlus's MLR does not meet the required minimum, HealthPlus will refund the difference to policyholders. HealthPlus has attempted to limit the rate increases to the lowest feasible level while preserving


the financial integrity of the products. This rate action is intended to keep the rates at an adequate level to compensate for both anticipated utilization and the annual increases in the cost of medical care (See description of health care costs below). Periodic rate adjustments are necessary to secure the ability of HealthPlus, like any health insurer, to produce sufficient revenue and surplus for reserves to assure continued coverage and claim payments both for current healthcare needs and potential catastrophic cost situations. HealthPlus's reserves vary from year to year based on actual healthcare costs incurred. Failing to meet the minimum statutory reserves will result in the insurer being deemed "impaired" under the New York Insurance Law. These reserves are the "insurance" that ensures payment even when costs run higher than anticipated or emergencies or disasters occur, and should not be used as an alternative fund to temporarily reduce rate adjustments. In filing this rate application we are sensitive to the fact that individuals struggle to afford health insurance coverage and we are seeking the appropriate premium necessary, as determined by our actuaries, to maintain a viable health plan. In our actuarial judgment it is clear that an increase in premiums is critical to ensure the viability of these products. Failure to approve these rates will likely lead to even greater rate increases and fewer product offerings in the future as claim costs will eventually exceed premiums collected.

II. FACTORS CONTRIBUTING TO THE PROPOSED RATE INCREASE Summary Factors that typically increase rates have been slightly more than offset by deeper discounts to providers by HealthPlus. The net rate increase is the result of the reinstatement of the ACA Health Insurer fee noted in Section IV. Escalating Health Care Costs

The cost of health care services and equipment continues to be the primary reason for rate increases. Nationally, the growth in the cost of medical care continues to significantly outpace consumer inflation. Health care spending growth is projected to grow faster than gross domestic product (GDP) over the next decade. A report by Price Waterhouse Coopers (PwC) projects health care costs to grow 6% in 2019.1 This has been the approximate rate of growth over the last several years. Health care cost and spending trends reflect underlying changes in the demographics and health status of America’s population. The aging population is driving some of the increase – as people age they typically utilize more health services. Between 2010 and 2050, the population aged 65 and older is expected to double, as the “baby boomer” population ages and life expectancy continues to rise2. Indeed the first baby boomers have now turned seventy and the percentage of workers over 65 is greater than at any period in history. As this population ages it will

1 Price Waterhouse Coopers (PwC) Health Research Institute, “Medical cost trend: Behind the numbers 2019”, June 2018 2 Center for Medicare & Medicaid Services, THE NEXT FOUR DECADES The Older Population in the United States: 2010 to 2050


correspond to a further escalation of costs. Moreover, the country’s general declining health and the increase in obesity and other health concerns, even at younger ages, forces average costs upward. Hospital Hospitals (inpatient and outpatient care) account for the largest share of the health care premium dollar in New York; a percentage that continues to grow. Factors driving this growth include increasing demand for care, rising costs to hospitals of the goods and services needed to provide care, and the growing intensity of care needs. The increase in cost for hospital inpatient care in HealthPlus's operating area continues to surpass the rate for the rest of the country. The increase in costs is exacerbated by the aggressive vertical and horizontal consolidation of hospital and other provider systems which has rarely resulted in increased efficiencies, but instead only increased the bargaining power of these institutions to demand higher reimbursement rates. Prescription Drugs Specialty drug spending continues to rise astronomically and while only a small subset of the population use specialty drugs, they currently account for a large percentage of total US drug spending, with that number expected to grow to 48% by 20203. Company Change In 2020, Empire HealthChoice Assurance's Individual products will be replaced with products offered by HealthPlus. The HealthPlus network will provide greater symmetry with other Individual products offered by HealthPlus, such as the Essential Plan and Child Health Plus. The favorability of HealthPlus’ revised reimbursement schedule also reduces some hospital costs, which in turn lowers overall cost for members. Furthermore, HealthPlus believes that additional morbidity improvement will be realized due to the anticipated healthier risk cohort of new members. III. ADMINISTRATIVE SAVINGS Recognizing the impact that rate increases will have on our customers, HealthPlus attempts to mitigate their impact by controlling and, if possible, reducing selected administrative costs to offset increases that are necessary or beyond our control. Our corporate culture emphasizes continuous improvements in all areas of the company with a focus on administrative savings and improving member and customer services. While we continue to strive to judiciously reduce administrative costs further, we want to avoid sacrificing customer service, which we believe would be at risk by further cost reductions.

3 Magellan Rx Management, EMPLOYER MARKET INSIGHTS REPORT, 2018 First Edition


IV. HISTORICAL FACTORS State and Federal Taxes New York adds more insurance taxes and assessments than any other state in the country. These consist of both direct taxes and a number of indirect taxes amounting to an annual total of over $6.5 billion in taxes passed on to New York healthcare customers in the form of higher premiums. These taxes include:

• NYS Premium Tax – this 1.75% tax is on all HMO and insurance contracts (and there is an additional amount for customers in the Metropolitan Transit Authority service area).

• Covered Lives Assessment – this indirect tax is a charge on all fully and self- insured “covered lives”. The purpose of the Covered Lives Assessment is to raise funds for a variety of state programs and for the state budget. The Assessment is included in claims costs for purposes of calculating the MLR. This assessment is currently a charge of from $3.00 to $14.87 per individual contract per month and from $9.98 to $49.06 per family contract per month.

• HCRA Surcharge – this is a 9.63% surcharge on all hospital discharges. The purpose of the HCRA Surcharge is to raise funds for a variety of state programs and for the state budget. The Surcharge is included in claims costs for purposes of calculating the MLR.

• NYS Insurance Department “206” Assessment – while this assessment is intended to fund the cost of the Department’s regulatory activities, it constitutes an indirect tax whereby a large portion of the revenue generated by the assessment continues to be used to fund other programs not directly related to insurance regulation. This assessment is charged to insurers based on their premium volume.

ACA related taxes and fees – these are various fees set forth in the ACA. This includes the ACA Health Insurer fee which has been reinstated in 2020 and impacts premiums by 2.78%. Each of these current taxes and fees contribute significantly to the cost of coverage and will vary from year to year as the number of covered lives increases or decreases and the number of hospital discharges vary.

V. DETAILS OF THE PROPOSED RATE INCREASE The proposed premium rates affect approximately:

• 18,700 on-exchange individual members • 3,450 off-exchange individual members

Premium rates for community-rated customers are regulated by the Superintendent of Financial Services pursuant to Section 4308 or 3231 of the Insurance Law. The following tables show proposed annual rate changes for the indicated community rated products:


2020 Plan Name Rating Area 1

Rating Area 3

Rating Area 4

Rating Area 7

Rating Area 8

HealthPlus Gatekeeper X, Catastrophic, ST, INN, Pediatric Dental -3.0% -3.0% -3.0% -3.0% 6.7%

HealthPlus Gatekeeper X, for HSA, Bronze, ST, INN, Pediatric Dental, Dep 25 -1.4% -1.4% -1.3% -1.4% 8.5%

HealthPlus Gatekeeper X, Silver, ST, INN, Pediatric Dental, Dep 25 -1.2% -1.2% -1.2% -1.2% 8.6%

HealthPlus Gatekeeper X, Gold, ST, INN, Pediatric Dental, Dep 25 -1.2% -1.2% -1.2% -1.2% 8.7%

HealthPlus Gatekeeper X, Platinum, ST, INN, Pediatric Dental, Dep 25 -1.2% -1.2% -1.2% -1.2% 8.7%

EXHIBIT 13C ‐ AVERAGE PREMIUM DETAILS

Company Name: Empire Healthchoice Assurance HealthPlus HP, LLCNAIC Code: 55093 16574

SERFF Tracking #: AWLP-131950100Market Segment: Individual

1 Please complete all of the shaded boxes in rows 24‐47 below. The goal of this Exhibit is to calculate the rate change being requested in a consistent manner for all insurers. 2 The "Weighted Average Monthly Base Premiums" in cells C24‐G31 should be calculated as a weighted average of the insurer's base premiums (i.e., single adult rates prior to application of tier factors, etc.) using the number of plan subscribers as the weights. 3 Cells L24 ‐ P31, should be a recalculation of cells C24‐G31 where any plans (and associated members enrolled in those plans as of 3/31/2019) that will no longer be offered in 2020 are removed.The sum of cells C37‐G44 should be equal to the Company's total membership for the relevant market as of 3/31/2019.

4 Cells L37‐P44 should be equal to cells C37‐G44 less any members that are enrolled in plans that will no longer be offered in 2020.5 If the Company is not eliminating any plans in 2020, then cells C24‐G31 and L24‐P31 should be the same, as should cells C37‐G44 and L37‐P44.6 The "Conversion Factors" should be the factors that were developed in pricing to convert the "Weighted Average Monthly Base Premiums" to "Weighted Average Monthly PMPM Premium Rates". These factors should be adjusted as necessary to reflect any changes that are not reflected in the Base Premiums.7 The value in cell Q74 of this Exhibit should match cell D96 (Line 54) of Exhibit 18.8 The value in cell Z74 of this Exhibit should match cell D102 (Line 56) of Exhibit 18.

2019 Weighted Average Monthly Base Premiums ‐ CALCULATED BASED ON ACTUAL DISTRIBUTION AS OF 3/31/2019 (Weighted by number 2019 Weighted Average Monthly Base Premiums ‐ RE‐CALCULATED USING ONLY THE SUBSET OF 2019 PLANS THAT WILL STILL 2020 Weighted Average Monthly Proposed Base Premiums ‐ THESE BASE PREMIUMS SHOULD BE CALCULATED USING THE SAME Change in Weighted Average Monthly Base Premiumsof subscribers) BE AVAILABLE IN 2020 (weighted by subscribers in those specific plans) POPULATION OF SUBSCRIBERS THAT WAS USED TO CALCULATE CELLS L22 ‐ P29)

Average Monthly Base Premium assuming 3/31/2019 membership Average Monthly Base Premium paid assuming 3/31/2019 membership and all policies are paid in full for the entire year) Average Base Premium paid assuming 3/31/2019 membership and all policies are paid in full for the entire year) Average Base Premium paid assuming 3/31/2019 membership and all policies are paid in full for the entire year)Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals

1 ‐ Albany Area 1142.39 962.58 754.02 570.13 251.13 843.52 1 ‐ Albany Area 1142.39 962.58 754.02 570.13 251.13 843.52 1 ‐ Albany Area 1128.90 951.42 744.83 562.41 243.67 833.20 1 ‐ Albany Area ‐1.18% ‐1.16% ‐1.22% ‐1.35% ‐2.97% ‐1.22%2 ‐Buffalo Area 0.00 0.00 0.00 0.00 0.00 2 ‐Buffalo Area 0.00 0.00 0.00 0.00 0.00 2 ‐Buffalo Area 0.00 0.00 0.00 0.00 0.00 2 ‐Buffalo Area

3‐ Mid‐Hudson Area 1355.96 1122.51 904.13 666.36 296.21 968.46 3‐ Mid‐Hudson Area 1355.96 1122.51 904.13 666.36 296.21 968.46 3‐ Mid‐Hudson Area 1339.94 1109.54 893.11 657.34 287.41 956.55 3‐ Mid‐Hudson Area ‐1.18% ‐1.16% ‐1.22% ‐1.35% ‐2.97% ‐1.23%4‐ NYC Area 1354.06 1115.86 897.75 658.00 295.25 940.08 4‐ NYC Area 1354.06 1115.86 897.75 658.00 295.25 940.08 4‐ NYC Area 1338.18 1103.08 886.89 649.14 286.50 928.54 4‐ NYC Area ‐1.17% ‐1.15% ‐1.21% ‐1.35% ‐2.96% ‐1.23%

5‐ Rochester Area 0.00 0.00 0.00 0.00 0.00 5‐ Rochester Area 0.00 0.00 0.00 0.00 0.00 5‐ Rochester Area 0.00 0.00 0.00 0.00 0.00 5‐ Rochester Area6‐ Syracuse Area 0.00 0.00 0.00 0.00 0.00 6‐ Syracuse Area 0.00 0.00 0.00 0.00 0.00 6‐ Syracuse Area 0.00 0.00 0.00 0.00 0.00 6‐ Syracuse Area

7‐ Utica/Watertown Area 0.00 0.00 0.00 0.00 0.00 7‐ Utica/Watertown Area 0.00 0.00 0.00 0.00 0.00 7‐ Utica/Watertown Area 0.00 0.00 0.00 0.00 0.00 7‐ Utica/Watertown Area8‐ Long Island Area 1088.49 897.29 719.46 532.56 236.26 778.18 8‐ Long Island Area 1088.49 897.29 719.46 532.56 236.26 778.18 8‐ Long Island Area 1183.00 975.46 781.64 577.80 252.12 845.44 8‐ Long Island Area 8.68% 8.71% 8.64% 8.49% 6.71% 8.64%

9 ‐ All Regions 1254.60 1004.86 822.16 613.24 282.65 873.98 9 ‐ All Regions 1254.60 1004.86 822.16 613.24 282.65 873.98 To Exhibit 13a (Section A) 9 ‐ All Regions 1279.42 1037.97 842.02 623.58 279.06 894.62 To Exhibit 13a (Section A) 9 ‐ All Regions 1.98% 3.30% 2.42% 1.69% ‐1.27% 2.36%

2019 Members ‐ as of 3/31/2019 ‐ Actual Distribution (All members as of 3/31/2019 should be included) Members ‐ as of 3/31/2019 ‐ Only those members currently enrolled in plans that will continue to be offered in 2020 Members ‐ as of 3/31/2019 ‐ Only those members currently enrolled in plans that will continue to be offered in 2020 Change in Members ‐ as of 3/31/2019 ‐ Change due to current 2019 plans not being offered in 2020.

Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals1 ‐ Albany Area 30 24 42 23 3 122 1 ‐ Albany Area 30 24 42 23 3 122 1 ‐ Albany Area 30 24 42 23 3 122 1 ‐ Albany Area 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%2 ‐Buffalo Area ‐ ‐ ‐ ‐ ‐ 2 ‐Buffalo Area ‐ ‐ ‐ ‐ ‐ 2 ‐Buffalo Area 2 ‐Buffalo Area

3‐ Mid‐Hudson Area 87 76 158 90 12 423 3‐ Mid‐Hudson Area 87 76 158 90 12 423 3‐ Mid‐Hudson Area 87 76 158 90 12 423 3‐ Mid‐Hudson Area 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%4‐ NYC Area 2,327 2,044 4,697 3,129 374 12,571 4‐ NYC Area 2,327 2,044 4,697 3,129 374 12,571 4‐ NYC Area 2,327 2,044 4,697 3,129 374 12,571 4‐ NYC Area 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

5‐ Rochester Area ‐ ‐ ‐ ‐ ‐ 5‐ Rochester Area ‐ ‐ ‐ ‐ ‐ 5‐ Rochester Area 5‐ Rochester Area6‐ Syracuse Area ‐ ‐ ‐ ‐ ‐ 6‐ Syracuse Area ‐ ‐ ‐ ‐ ‐ 6‐ Syracuse Area 6‐ Syracuse Area

7‐ Utica/Watertown Area ‐ ‐ ‐ ‐ ‐ 7‐ Utica/Watertown Area ‐ ‐ ‐ ‐ ‐ 7‐ Utica/Watertown Area 7‐ Utica/Watertown Area8‐ Long Island Area 1,426 2,183 3,556 1,783 103 9,051 8‐ Long Island Area 1,426 2,183 3,556 1,783 103 9,051 8‐ Long Island Area 1,426 2,183 3,556 1,783 103 9,051 8‐ Long Island Area 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

9 ‐ All Regions 3,870 4,327 8,453 5,025 492 22,167 9 ‐ All Regions 3,870 4,327 8,453 5,025 492 22,167 Should equal Cell H‐24 of Exhibit 14 9 ‐ All Regions 3,870 4,327 8,453 5,025 492 22,167 9 ‐ All Regions 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

2019 Conversion Factor ‐ A 0.8698 Must be less than or equal to 1.000 2019 Conversion Factor ‐ B 0.8698 Must be less than or equal to 1.000 2020 Conversion Factor 0.8698 Must be less than or equal to 1.000 Change in Conversion Factor 0.00006%

2019 Estimated Aggregate Annualized Premium by Metal and Region ‐ based on membership as of 3/31/2019 2019 Estimated Aggregate Annualized Premium by Metal and Region ‐ based on membership as of 3/31/2019 2020 Estimated Aggregate Annualized Premium by Metal and Region ‐ based on membership as of 3/31/2019 Change in Aggregate Annualized Premiums ‐ based on membership as of 3/31/2019 (Ignoring any plan eliminations) Aggregate premium that would be collected assuming 3/31/2019 membership and all policies are paid in full for the entire year) Aggregate premium that would be collected assuming 3/31/2019 membership and all policies are paid in full for the entire year) ‐ Adjusted for plan eliminations Aggregate premium that would be collected assuming 3/31/2019 membership and all policies are paid in full for the entire year) ‐ Adjusted for plan eliminations

Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals1 ‐ Albany Area 357,711 241,126 330,545 136,867 7,864 1,074,113 1 ‐ Albany Area 357,711 241,126 330,545 136,867 7,864 1,074,113 1 ‐ Albany Area 353,488 238,332 326,514 135,014 7,630 1,060,979 1 ‐ Albany Area ‐1.18% ‐1.16% ‐1.22% ‐1.35% ‐2.97% ‐1.22%2 ‐Buffalo Area ‐ ‐ ‐ ‐ ‐ ‐ 2 ‐Buffalo Area ‐ ‐ ‐ ‐ ‐ ‐ 2 ‐Buffalo Area 2 ‐Buffalo Area

3‐ Mid‐Hudson Area 1,231,296 890,430 1,491,021 625,961 37,100 4,275,809 3‐ Mid‐Hudson Area 1,231,296 890,430 1,491,021 625,961 37,100 4,275,809 3‐ Mid‐Hudson Area 1,216,753 880,144 1,472,846 617,486 35,998 4,223,227 3‐ Mid‐Hudson Area ‐1.18% ‐1.16% ‐1.22% ‐1.35% ‐2.97% ‐1.23%4‐ NYC Area 32,887,374 23,806,011 44,012,283 21,489,635 1,152,545 123,347,849 4‐ NYC Area 32,887,374 23,806,011 44,012,283 21,489,635 1,152,545 123,347,849 4‐ NYC Area 32,501,826 23,533,360 43,479,694 21,200,284 1,118,393 121,833,557 4‐ NYC Area ‐1.17% ‐1.15% ‐1.21% ‐1.35% ‐2.96% ‐1.23%

5‐ Rochester Area ‐ ‐ ‐ ‐ ‐ ‐ 5‐ Rochester Area ‐ ‐ ‐ ‐ ‐ ‐ 5‐ Rochester Area 5‐ Rochester Area6‐ Syracuse Area ‐ ‐ ‐ ‐ ‐ ‐ 6‐ Syracuse Area ‐ ‐ ‐ ‐ ‐ ‐ 6‐ Syracuse Area 6‐ Syracuse Area

7‐ Utica/Watertown Area ‐ ‐ ‐ ‐ ‐ ‐ 7‐ Utica/Watertown Area ‐ ‐ ‐ ‐ ‐ ‐ 7‐ Utica/Watertown Area 7‐ Utica/Watertown Area8‐ Long Island Area 16,200,995 20,444,795 26,703,454 9,911,001 253,994 73,514,239 8‐ Long Island Area 16,200,995 20,444,795 26,703,454 9,911,001 253,994 73,514,239 8‐ Long Island Area 17,607,600 22,226,040 29,011,088 10,752,919 271,047 79,868,694 8‐ Long Island Area 8.68% 8.71% 8.64% 8.49% 6.71% 8.64%

9 ‐ All Regions 50,677,377 45,382,362 72,537,303 32,163,464 1,451,503 202,212,010 9 ‐ All Regions 50,677,377 45,382,362 72,537,303 32,163,464 1,451,503 202,212,010 Should equal Cell G‐24 of Exhibit 14 9 ‐ All Regions 51,679,667 46,877,876 74,290,142 32,705,703 1,433,068 206,986,456 9 ‐ All Regions 1.98% 3.30% 2.42% 1.69% ‐1.27% 2.36%

2019 Weighted Average Monthly PMPM Premium Rates 2019 Weighted Average Monthly PMPM Premium Rates ‐ Reflecting adjustment for eliminated plans 2020 Weighted Average Monthly PMPM Premium Rates ‐Reflecting adjustment for eliminated plans Change in Weighted Average PMPM Premiums

Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals1 ‐ Albany Area 993.64 837.24 655.84 495.89 218.43 733.68 1 ‐ Albany Area 993.64 837.24 655.84 495.89 218.43 733.68 1 ‐ Albany Area 981.91 827.54 647.85 489.18 211.94 724.71 1 ‐ Albany Area ‐1.18% ‐1.16% ‐1.22% ‐1.35% ‐2.97% ‐1.22%2 ‐Buffalo Area 2 ‐Buffalo Area 2 ‐Buffalo Area 2 ‐Buffalo Area

3‐ Mid‐Hudson Area 1,179.40 976.35 786.40 579.59 257.64 842.36 3‐ Mid‐Hudson Area 1,179.40 976.35 786.40 579.59 257.64 842.36 3‐ Mid‐Hudson Area 1,165.47 965.07 776.82 571.75 249.98 832.00 3‐ Mid‐Hudson Area ‐1.18% ‐1.16% ‐1.22% ‐1.35% ‐2.97% ‐1.23%4‐ NYC Area 1,177.75 970.56 780.86 572.32 256.81 817.67 4‐ NYC Area 1,177.75 970.56 780.86 572.32 256.81 817.67 4‐ NYC Area 1,163.94 959.45 771.41 564.62 249.20 807.64 4‐ NYC Area ‐1.17% ‐1.15% ‐1.21% ‐1.35% ‐2.96% ‐1.23%

5‐ Rochester Area 5‐ Rochester Area 5‐ Rochester Area 5‐ Rochester Area6‐ Syracuse Area 6‐ Syracuse Area 6‐ Syracuse Area 6‐ Syracuse Area

7‐ Utica/Watertown Area 7‐ Utica/Watertown Area 7‐ Utica/Watertown Area 7‐ Utica/Watertown Area8‐ Long Island Area 946.76 780.45 625.78 463.22 205.50 676.85 8‐ Long Island Area 946.76 780.45 625.78 463.22 205.50 676.85 8‐ Long Island Area 1,028.96 848.45 679.86 502.57 219.29 735.36 8‐ Long Island Area 8.68% 8.71% 8.64% 8.49% 6.71% 8.64%

9 ‐ All Regions 1,091.24 874.02 715.10 533.39 245.85 760.18 9 ‐ All Regions 1,091.24 874.02 715.10 533.39 245.85 760.18 To Exhibit 13a (Section B) 9 ‐ All Regions 1,112.83 902.82 732.38 542.38 242.73 778.13 To Exhibit 13a (Section B) Total 1.98% 3.30% 2.42% 1.69% ‐1.27% 2.36%

Exhibit 13c Updated by DFS 3/14/2018 1

DFS

Cross-Out

DFS

Cross-Out

DFS

Cross-Out

DFS

Cross-Out

DFS

Cross-Out

Company Name: Empire Healthchoice Assurance HealthPlus HP, LLCNAIC Code: 55093 16574 NOTE: THIS EXHIBIT SHOULD NOT INCLUDE MEMBERS THAT ARE CURRENTLY ENROLLED IN PLANS THAT WILL NOT BE AVAILABLE IN 2020SERFF Tracking #: AWLP-131950100 Market Segment: Individual

12345

6789

10111213 The Total Annualized Premium in Cell G-24 of this Exhibit should equal the total in Cell Q-61 of Exhibit 13c.14 The Total Number of Members in Cell H-24 of this Exhibit should equal the total in Cell Q-45 of Exhibit 13c (i.e., Only those members currently enrolled in plans that will continue to be offered in 2020)

Totals $202,212,010 22,167 15,086

Annualized Premiums as of Total # of Members as of

Total # of Contracts (Certificates for SG) as of

3/31/2019 3/31/2019 3/31/2019 Decrease No Change 0.1% - 4.9% 5.0% - 9.9% 10.0% - 14.9% 15.0% - 19.9% 20.0% - 24.9% 25.0% - 29.9% 30.0% - 39.9% 40.0% - 49.9% 50.0% or higher Lowest Highest Weighted Avg

Individual 01/01/20 Catastrophic 1 - Albany Area

HealthPlus Gatekeeper X, Catastrophic, ST, INN,

Pediatric Dental $7,834 3 3 3 0 0 0 0 0 0 0 0 0 0 -2.97% -2.97% -2.97%

Individual 01/01/20 Catastrophic 3 - Mid Hudson Area



Individual 01/01/20 Catastrophic 4 - New York City Area


Pediatric Dental $1,148,264 374 362 374 0 0 0 0 0 0 0 0 0 0 -2.96% -2.96% -2.96%

Individual 01/01/20 Catastrophic 7 - Utica/Watertown Area


Pediatric Dental $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -2.97% -2.97% -2.97%

Individual 01/01/20 Catastrophic 8 - Long Island Area


Pediatric Dental $253,051 103 101 0 0 0 103 0 0 0 0 0 0 0 6.71% 6.71% 6.71%

Individual 01/01/20 Bronze 1 - Albany Area

HealthPlus Gatekeeper for HSA, Bronze, ST, INN,

Pediatric Dental, Child Only, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.64% -1.64% -1.64%



Pediatric Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.35% -1.35% -1.35%





HealthPlus Gatekeeper X, for HSA, Bronze, ST, INN,

Pediatric Dental, Child Only $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.62% -1.62% -1.62%



Pediatric Dental, Dep 25 $136,358 23 19 23 0 0 0 0 0 0 0 0 0 0 -1.35% -1.35% -1.35%



Pediatric Dental, Dep 29 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.31% -1.31% -1.31%

Individual 01/01/20 Bronze 3 - Mid Hudson Area











Pediatric Dental, Child Only $2,876 1 1 1 0 0 0 0 0 0 0 0 0 0 -1.62% -1.62% -1.62%







Individual 01/01/20 Bronze 4 - New York City Area











Pediatric Dental, Child Only $223,572 78 67 78 0 0 0 0 0 0 0 0 0 0 -1.61% -1.61% -1.61%



Pediatric Dental, Dep 25 $20,937,750 3,004 2,046 3,004 0 0 0 0 0 0 0 0 0 0 -1.34% -1.34% -1.34%




Individual 01/01/20 Bronze 7 - Utica/Watertown Area











Pediatric Dental, Child Only $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.62% -1.62% -1.62%







Individual 01/01/20 Bronze 8 - Long Island Area


Pediatric Dental, Child Only, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.19% 8.19% 8.19%



Pediatric Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.50% 8.50% 8.50%



Pediatric Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.54% 8.54% 8.54%

The weighted average percentage should be developed based on annualized premium volume or membership for that metal level, and rating region, including any applicable riders.

EXHIBIT 14: SUMMARY OF REQUESTED PERCENTAGE CHANGES

Use this Exhibit for both Individual and Small Group Market Plans. A separate Exhibit should be provided for Individual and Small Group filings.Market segment refers to Individual (which includes Catastrophic) or Small Group.The requested percentage rate change reflects the expected change in premium rates that would apply to the contract holder (or member for Small Group business) on that contract holder's next rate change date for each contract holder within the indicated combination of metal level, rating region, and product name.The "Product Street Name" is the product name as advertised to consumers (i.e., as consumers are likely to refer to this product/metal level when communicating with DFS). A separate row is to be used for each combination of metal level, rating region and product name.

If the percentage changes (lowest and highest and weighted average) are identical for all the rating regions, then separate rows by rating region need not be used, and "All Regions" can be shown in the Rating Region column. If the rate change range information differs by rating region, then separate rows need to be used for each rating region the insurer uses. Rating region names used on this exhibit are to use the standard rating region names developed by DFS (e.g., Albany Area, Buffalo Area, etc.).The "requested rate change" includes the impact of any riders (such as: age 29, domestic partner, family planning, pediatric dental, etc.)."Lowest" should be the smallest percentage change that could affect any contract holder due to the submitted rate filing with that metal level and rating region, including any applicable riders."Highest" should be the largest percentage change that could affect any contract holder due to the submitted rate filing with that metal level and rating region, including any applicable riders.

The effective date is the earliest date that the proposed new rate would become effective if approved. The Effective Date for Individual is 1/1/2020. Effective Dates for Small Group are 1/1/2020, 4/1/2020, 7/1/2020 and 10/1/2020.

Requested Percentage Rate Change

Percentage Rate Changes should be calculated using membership as of 3/31/2019.This exhibit must be submitted as an Excel file and as a PDF file.

Market Segment Effective Date of New RateMetal Level

(or Catastrophic) Rating Region Product Name Product Street NameDISTRIBUTION OF MEMBERS - Number of Members with Requested Percentage Rate Change at Renewal

Exhibit 14 Updated by DFS 3/14/2018 1

DFS

Cross-Out

DFS

Cross-Out



Pediatric Dental, Child Only $32,110 14 14 0 0 0 14 0 0 0 0 0 0 0 8.21% 8.21% 8.21%



Pediatric Dental, Dep 25 $9,637,676 1,728 1,078 0 0 0 1,728 0 0 0 0 0 0 0 8.50% 8.50% 8.50%



Pediatric Dental, Dep 29 $238,064 41 11 0 0 0 41 0 0 0 0 0 0 0 8.54% 8.54% 8.54%

Individual 01/01/20 Silver 1 - Albany Area

HealthPlus Gatekeeper X, Silver Child Only, ST, INN,



HealthPlus Gatekeeper X, Silver, ST, INN, Pediatric

Dental, Dep 25 $328,369 41 27 41 0 0 0 0 0 0 0 0 0 0 -1.22% -1.22% -1.22%



Dental, Dep 29 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.20% -1.20% -1.20%


HealthPlus Gatekeeper, Silver Child Only, ST, INN, Pediatric

Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.07% -1.07% -1.07%


HealthPlus Gatekeeper, Silver, ST, INN, Pediatric

Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.21% -1.21% -1.21%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.20% -1.20% -1.20%

Individual 01/01/20 Silver 3 - Mid Hudson Area





Dental, Dep 25 $1,464,178 155 114 155 0 0 0 0 0 0 0 0 0 0 -1.22% -1.22% -1.22%



Dental, Dep 29 $19,668 2 1 2 0 0 0 0 0 0 0 0 0 0 -1.20% -1.20% -1.20%



Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.07% -1.07% -1.07%



Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.21% -1.21% -1.21%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.20% -1.20% -1.20%

Individual 01/01/20 Silver 4 - New York City Area





Dental, Dep 25 $42,982,844 4,565 3,173 4,565 0 0 0 0 0 0 0 0 0 0 -1.21% -1.21% -1.21%



Dental, Dep 29 $803,768 82 27 82 0 0 0 0 0 0 0 0 0 0 -1.19% -1.19% -1.19%



Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.06% -1.06% -1.06%



Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.20% -1.20% -1.20%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.19% -1.19% -1.19%

Individual 01/01/20 Silver 7 - Utica/Watertown Area





Dental, Dep 25 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.22% -1.22% -1.22%



Dental, Dep 29 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.20% -1.20% -1.20%



Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.07% -1.07% -1.07%



Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.21% -1.21% -1.21%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.20% -1.20% -1.20%

Individual 01/01/20 Silver 8 - Long Island Area





Dental, Dep 25 $25,926,228 3,441 2,141 0 0 0 3,441 0 0 0 0 0 0 0 8.64% 8.64% 8.64%



Dental, Dep 29 $682,398 87 25 0 0 0 87 0 0 0 0 0 0 0 8.67% 8.67% 8.67%



Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.80% 8.80% 8.80%



Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.65% 8.65% 8.65%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.66% 8.66% 8.66%

Individual 01/01/20 Gold 1 - Albany Area

HealthPlus Gatekeeper X, Gold Child Only, ST, INN,



HealthPlus Gatekeeper X, Gold, ST, INN, Pediatric

Dental, Dep 25 $240,231 24 18 24 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%



Dental, Dep 29 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.14% -1.14% -1.14%


HealthPlus Gatekeeper, Gold Child Only, ST, INN, Pediatric

Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -0.85% -0.85% -0.85%


HealthPlus Gatekeeper, Gold, ST, INN, Pediatric Dental,

Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%



Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.15% -1.15% -1.15%

Individual 01/01/20 Gold 3 - Mid Hudson Area





Dental, Dep 25 $885,449 75 51 75 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%



Dental, Dep 29 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.14% -1.14% -1.14%



Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -0.85% -0.85% -0.85%



Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%



Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.15% -1.15% -1.15%

Individual 01/01/20 Gold 4 - New York City Area





Dental, Dep 25 $23,005,898 1,955 1,461 1,955 0 0 0 0 0 0 0 0 0 0 -1.15% -1.15% -1.15%



Dental, Dep 29 $637,017 52 15 52 0 0 0 0 0 0 0 0 0 0 -1.13% -1.13% -1.13%




Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -0.84% -0.84% -0.84%



Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.15% -1.15% -1.15%



Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.14% -1.14% -1.14%

Individual 01/01/20 Gold 7 - Utica/Watertown Area





Dental, Dep 25 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%



Dental, Dep 29 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.14% -1.14% -1.14%



Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -0.85% -0.85% -0.85%



Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.15% -1.15% -1.15%



Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.14% -1.14% -1.14%

Individual 01/01/20 Gold 8 - Long Island Area





Dental, Dep 25 $19,238,052 2,043 1,155 0 0 0 2,043 0 0 0 0 0 0 0 8.71% 8.71% 8.71%



Dental, Dep 29 $1,166,531 119 32 0 0 0 119 0 0 0 0 0 0 0 8.73% 8.73% 8.73%



Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 9.04% 9.04% 9.04%



Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.71% 8.71% 8.71%



Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.72% 8.72% 8.72%

Individual 01/01/20 Platinum 1 - Albany Area

HealthPlus Gatekeeper X, Platinum Child Only, ST, INN,



HealthPlus Gatekeeper X, Platinum, ST, INN, Pediatric

Dental, Dep 25 $353,140 29 23 29 0 0 0 0 0 0 0 0 0 0 -1.19% -1.19% -1.19%



Dental, Dep 29 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%


HealthPlus Gatekeeper, Platinum Child Only, ST, INN,

Pediatric Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -0.74% -0.74% -0.74%


HealthPlus Gatekeeper, Platinum, ST, INN, Pediatric

Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.19% -1.19% -1.19%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.17% -1.17% -1.17%

Individual 01/01/20 Platinum 3 - Mid Hudson Area





Dental, Dep 25 $1,177,744 82 59 82 0 0 0 0 0 0 0 0 0 0 -1.19% -1.19% -1.19%



Dental, Dep 29 $44,849 3 1 3 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%






Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.19% -1.19% -1.19%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.17% -1.17% -1.17%

Individual 01/01/20 Platinum 4 - New York City Area





Dental, Dep 25 $31,295,081 2,186 1,770 2,186 0 0 0 0 0 0 0 0 0 0 -1.18% -1.18% -1.18%



Dental, Dep 29 $1,192,102 80 39 80 0 0 0 0 0 0 0 0 0 0 -1.15% -1.15% -1.15%






Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.18% -1.18% -1.18%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%

Individual 01/01/20 Platinum 7 - Utica/Watertown Area





Dental, Dep 25 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.19% -1.19% -1.19%



Dental, Dep 29 $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.16% -1.16% -1.16%






Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.19% -1.19% -1.19%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1.17% -1.17% -1.17%

Individual 01/01/20 Platinum 8 - Long Island Area





Dental, Dep 25 $15,339,264 1,339 927 0 0 0 1,339 0 0 0 0 0 0 0 8.68% 8.68% 8.68%



Dental, Dep 29 $775,061 65 19 0 0 0 65 0 0 0 0 0 0 0 8.70% 8.70% 8.70%



Pediatric Dental, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 9.16% 9.16% 9.16%



Dental, Dep 25, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.68% 8.68% 8.68%



Dental, Dep 29, SNF $0 0 0 0 0 0 0 0 0 0 0 0 0 0 8.69% 8.69% 8.69%



Company Name: Empire Healthchoice Assurance HealthPlus HP, LLCNAIC Code: 55093 16574SERFF Number: AWLP-131950100Market Segment: Individual

Instructions:1) This Exhibit summarizes all benefit/rate changes filed after the initial rate filing that impacts the rate tables in this current filing.2)3)4) Extend the worksheet to add more rows as needed. Only use the first tab for data entry.5)

Filing Status SERFF # NY State Tracking # Date of Submission Policy Form #Product Name (including Street

Name)Brief Description of Benefit/Rate

Change Approval Date

EXHIBIT 16: SUMMARY OF POLICY FORM AND PRODUCT CHANGES

The product street name is the product name as advertised to consumers (i.e., as consumers are likely to refer to this product/policy form when communicating with DFS).Enter filing status (approved or pending) using the drop down list. For pending files leave the approval date blank.

This form must be submitted as an Excel file and as a PDF file.

List of rate filings that have been approved since the §3231(d) or §4308(b) initial rate filing, or are currently pending with DFS.

DFS

Cross-Out

DFS

Cross-Out

EXHIBIT 17: HISTORICAL CLAIM DATA BY POLICY FORMS INCLUDED IN RATE ADJUSTMENT FILING

Company Name:

NAIC Code:

SERFF Number:

Market Segment:

1 Complete a separate ROW for each relevant policy form as indicated below.

• Information requested applies to New York State business only for each rating region and all regions combined.

• Include riders that may be available with that policy form in each policy form response. Discontinued policy forms and products are to be included in the Exhibit.

• Complete additional rows as needed to include all base medical policy forms that were offered in the applicable market segment.

2 This Exhibit must report the latest two years of experience for the following categories of business, broken out by rating region, and for all regions combined:

Market Description

Market Segment (Entry for

Exhibit 17, Column 4)

Group

Definition Counting Method Notes Standardized Premium Scale

Individual ACA Compliant Individual Plans Individual‐ACA N/A N/A Issued on or after 1/1/2016 2019 Rates

Catastrophic ACA Compliant Catastrophic Plans Catastrophic N/A N/A Issued on or after 1/1/2016 2019 Rates

Small Group

Experience of ACA Compliant Small Group Plans

(Excluding Healthy New York plans) that were

written or renewed on or after 1/1/2016 SG‐ACA‐FTE 1‐100

Current New York

(FTE)

All relevant experience in

the calendar year

4th Quarter 2019 for rolling;

2019 for non‐rolling

Small Group ‐ HNY

Experience of Small Group Healthy New York Plans

that were written or renewed on or after 1/1/2016 SG‐ACA‐HNY‐FTE 1‐50

Current New York

(FTE)

All relevant experience in

the calendar year

4th Quarter 2019 for rolling;

2019 for non‐rolling

3 Product type is HMO, HMO based POS, POS‐OON, EPO, PPO, Comprehensive Major Medical, Non‐HMO based POS, and Consumer Health Plans. Indicate appropriate designation for policy form, etc.

4 The product street name is the product name as advertised to consumers (i.e., as consumers are likely to refer to this product/policy form when communicating with DFS.

5 Paid claims in Columns 14.6 ‐ 14.7 and 15.6 ‐ 15.7 are all claims paid during experience period that are attributed to the calendar year in question.

6 If members, covered lives or member months are not known, use reasonable estimates (note methodology used in the actuarial memorandum).

7 This exhibit must be submitted as an Excel file and as a PDF file. Only use the first tab for data entry.

8 These categories should be mutually exclusive (i.e., the sum of the values in a particular column should represent the total for the entire legal entity.

9 With regard to Small Group, the experience reported in this Exhibit should include only business that was considered "Small Group" according to the applicable rules at the time the underlying policies were in‐force.

a. Any portion of a group's experience that was considered "Large" based on the rules that were applicable at that time, should not be included in this Exhibit.

Empire Healthchoice Assurance HealthPlus HP, LLC55093 16574

AWLP‐131950100

Individual

Exhibit 17 ‐ Instructions Last Updated 5/1/2017 1

DFS

Cross-Out

DFS

Cross-Out

1.a Company Name

1.b NAIC Code 1.c SERFF Number

1d.Base medical

policy form number

1e.Product Name

(per Rate Manual)

1f.Product

Street Name as indicated

to consumers2.

Filing Type

3.Effective date of last rate change

(mm/dd/yy)4.

Market Segment5A.

Rating Region

5B.Product Type (see "Instructions"

tab for examples)

6. Is a rolling

rate structure

used for this base

medical policy form? (Yes or No)

7.Is base medical policy form open

(new sales allowed) or closed

(no new sales)

8.Number of

policyholders affected by rate

change. (For group business this is number

of groups.)

9.Number of

covered lives affected by rate

changeEmpire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 1 - Albany Area EPO No Open 20 23 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 1 - Albany Area EPO No Open 84 113 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 1 - Albany Area EPO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 1 - Albany Area EPO No Open 1 1 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 1 - Albany Area EPO No Open 1 1 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 1 - Albany Area EPO No Open 4 4 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 1 - Albany Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_N Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 1 - Albany Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_MSP_NS_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 1 - Albany Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 3 - Mid-Hudson Area EPO No Open 149 217 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 3 - Mid-Hudson Area EPO No Open 207 297 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 3 - Mid-Hudson Area EPO No Open 1 1 Empire Healthchoice 55093 AWLP-131950100 NY_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 3 - Mid-Hudson Area EPO No Open 4 4 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 3 - Mid-Hudson Area EPO No Open 8 8 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 3 - Mid-Hudson Area EPO No Open 8 8 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 3 - Mid-Hudson Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_N Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 3 - Mid-Hudson Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_MSP_NS_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 3 - Mid-Hudson Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 4 - NYC Area EPO No Open 3,991 5,594 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 4 - NYC Area EPO No Open 5,770 8,226 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 4 - NYC Area EPO No Open 68 68 Empire Healthchoice 55093 AWLP-131950100 NY_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 4 - NYC Area EPO No Open 145 152 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 4 - NYC Area EPO No Open 158 162 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 4 - NYC Area EPO No Open 271 279 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 4 - NYC Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_N Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 4 - NYC Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_MSP_NS_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 4 - NYC Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 7 - Utica/Watertown Area EPO No Open 1 1 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 7 - Utica/Watertown Area EPO No Open 1 1 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 7 - Utica/Watertown Area EPO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 7 - Utica/Watertown Area EPO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 7 - Utica/Watertown Area EPO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 7 - Utica/Watertown Area EPO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 7 - Utica/Watertown Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_N Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 7 - Utica/Watertown Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_MSP_NS_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 7 - Utica/Watertown Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 8 - Long Island Area EPO No Open 2,549 4,198 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 8 - Long Island Area EPO No Open 2,284 3,797 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 8 - Long Island Area EPO No Open 39 39 Empire Healthchoice 55093 AWLP-131950100 NY_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 8 - Long Island Area EPO No Open 45 50 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 8 - Long Island Area EPO No Open 49 51 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 8 - Long Island Area EPO No Open 51 51 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 8 - Long Island Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_N Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 8 - Long Island Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_MSP_NS_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 8 - Long Island Area HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 9 - All Regions EPO No Open 6,710 10,033 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 9 - All Regions EPO No Open 8,346 12,434 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 9 - All Regions EPO No Open 108 108 Empire Healthchoice 55093 AWLP-131950100 NY_ Individual EPO Individual 3231(e)(1) 1/1/19 Individual-ACA 9 - All Regions EPO No Open 195 207 Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_S Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 9 - All Regions EPO No Open 216 222 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 3231(e)(1) 1/1/19 Catastrophic 9 - All Regions EPO No Open 334 342 Empire Healthchoice 55093 AWLP-131950100 NY_OFFHIX_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 9 - All Regions HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_ONHIX_N Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 9 - All Regions HMO No Open - - Empire Healthchoice 55093 AWLP-131950100 NY_MSP_NS_ Individual EPO Individual 4308(c) 1/1/18 Individual-ACA 9 - All Regions HMO No Open - -

Data Item for Specified Base Medical Policy Form


14.1Beginning Date

of the experience

period (mm/dd/y)

14.2Ending Date of the experience

period (mm/dd/yy)

14.3Member months for experience period

14.4Earned premiums for experience period ($)

14.5Standardized earned

premiums for experience period ($)

14.6 Claims Paid in calendar year 2018 on claims incurred during calendar year 2018 -

before any adjustment forfederal risk adjustment, federal reinsurance, risk corridors, state stop-loss

pools, or commercial stop-loss payments ($)

14.6a Claims Paid in calendar year 2019

(during the months of January and February

only) on claims incurred during calendar year 2018 - before any

adjustment for federal risk adjustment, federal

reinsurance, risk corridors, state stop-loss


14.6b Estimated claims remaining to be

paid in the future on claims incurred during

2018 - before any adjustment for federal

risk adjustment, federal reinsurance, risk

corridors, state stop-loss pools, or commercial

stop-loss payments ($)

14.6c Rx Rebates associated with claims

reported in Columns 14.6and 14.6a (enter as a

positive value) ($)

14.6d Estimated Rx Rebates associated with

claims reported in Column 14.6b or not otherwise included in

14.6c (enter as a positivevalue) ($)

14.7 Total Incurred Claims for

calendar year 2018 Net of Rx Rebates ($)

14.8Adjustment to the

incurred claims for the period due to receipts from state or federal

reinsurance or stop loss pools (enter receipts from

the pool as a negative value) ($)


incurred claims for the period due to receipts

from or payments to the federal risk adjustment

pool (enter receipts as a negative value and

payments to the pool as a positive value) ($)

14.10Administrative expenses

for experience period (including commissions and premium taxes, but excluding federal and

state income taxes) ($)

15.1Beginning date of the

experience period (mm/dd/yy)

15.2Ending Date of the experience period

(mm/dd/yy)1/1/2018 12/31/2018 331.00 284,239 284,239 712,517 16,275 12,287 8,792 0 $ 732,287.16 $ - $ (331,007) $ 37,512 1/1/2017 12/31/20171/1/2018 12/31/2018 1376.00 1,110,849 1,110,849 995,710 87,152 30,533 36,507 0 $ 1,076,887.78 $ - $ (564,349) $ 147,463 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 5.00 783 783 381 3 14 136 0 $ 260.83 $ - $ 1,509 $ 376 1/1/2017 12/31/20171/1/2018 12/31/2018 15.00 4,663 4,663 417 1 10 398 0 $ 29.08 $ - $ 1,133 $ 1,817 1/1/2017 12/31/20171/1/2018 12/31/2018 53.00 16,476 16,476 1,601 20 44 1,404 0 $ 261.06 $ - $ 3,463 $ 4,214 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 2821.00 2,577,995 2,577,995 2,841,749 235,956 80,562 75,214 1 $ 3,083,052.46 $ - $ (774,085) $ 324,921 1/1/2017 12/31/20171/1/2018 12/31/2018 4125.00 3,715,382 3,715,382 5,266,458 393,073 136,703 109,725 1 $ 5,686,508.00 $ - $ (2,041,859) $ 458,236 1/1/2017 12/31/20171/1/2018 12/31/2018 20.00 4,530 4,530 8,141 466 300 550 0 $ 8,357.99 $ - $ (27,423) $ 1,565 1/1/2017 12/31/20171/1/2018 12/31/2018 58.00 15,875 15,875 194,704 9,623 3,561 1,535 0 $ 206,353.31 $ - $ (127,978) $ 4,816 1/1/2017 12/31/20171/1/2018 12/31/2018 102.00 37,398 37,398 4,386 62 113 2,766 0 $ 1,795.10 $ - $ 7,202 $ 8,643 1/1/2017 12/31/20171/1/2018 12/31/2018 137.26 43,340 43,340 19,661 2,425 691 3,636 0 $ 19,141.20 $ - $ (1,622) $ 11,777 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 69740.86 60,589,266 60,589,266 67,643,228 4,591,954 1,748,523 1,858,113 20 $ 72,125,572.19 $ (444,471) $ (12,742,696) $ 7,934,080 1/1/2017 12/31/20171/1/2018 12/31/2018 107601.08 93,774,743 93,774,743 99,889,711 6,153,698 2,546,693 2,860,857 29 $ 105,729,215.60 $ - $ (21,230,108) $ 11,890,810 1/1/2017 12/31/20171/1/2018 12/31/2018 866.32 192,809 192,809 850,816 47,550 23,887 23,232 0 $ 899,020.54 $ - $ 38,482 $ 72,760 1/1/2017 12/31/20171/1/2018 12/31/2018 2101.65 373,263 373,263 1,211,539 45,291 28,759 56,944 1 $ 1,228,643.89 $ (332,377) $ 158,224 $ 181,374 1/1/2017 12/31/20171/1/2018 12/31/2018 2023.00 714,026 714,026 544,584 24,473 13,499 54,208 1 $ 528,347.51 $ - $ (290,561) $ 185,653 1/1/2017 12/31/20171/1/2018 12/31/2018 3887.27 1,366,250 1,366,250 626,780 17,084 13,968 103,710 1 $ 554,120.03 $ - $ (129,151) $ 348,930 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 12.00 21,992 21,992 129,538 785 1,508 318 0 $ 131,512.58 $ - $ (35,428) $ 1,839 1/1/2017 12/31/20171/1/2018 12/31/2018 12.00 21,992 21,992 28,785 2,304 792 318 0 $ 31,563.23 $ - $ (21,840) $ 1,839 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 52185.87 39,738,043 39,738,043 35,989,998 2,386,456 938,562 1,388,237 15 $ 37,926,763.84 $ - $ (5,376,056) $ 5,697,510 1/1/2017 12/31/20171/1/2018 12/31/2018 48769.86 36,297,718 36,297,718 41,139,201 2,851,368 1,095,167 1,296,686 14 $ 43,789,036.09 $ (253,513) $ (9,119,403) $ 5,220,192 1/1/2017 12/31/20171/1/2018 12/31/2018 449.10 98,108 98,108 180,423 9,570 4,376 12,062 0 $ 182,307.53 $ - $ 114,633 $ 38,245 1/1/2017 12/31/20171/1/2018 12/31/2018 601.33 111,513 111,513 160,992 8,620 4,388 16,044 0 $ 157,956.02 $ - $ 98,277 $ 53,883 1/1/2017 12/31/20171/1/2018 12/31/2018 595.00 186,556 186,556 39,464 2,182 1,321 15,952 0 $ 27,015.05 $ - $ 5,337 $ 53,175 1/1/2017 12/31/20171/1/2018 12/31/2018 737.48 228,577 228,577 42,438 1,527 951 19,591 0 $ 25,324.31 $ - $ (2,889) $ 65,868 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 125090.73 103,211,535 103,211,535 107,317,029 7,231,426 2,781,442 3,330,673 36 $ 113,999,188.24 $ (444,471) $ (19,259,272) $ 13,995,861 1/1/2017 12/31/20171/1/2018 12/31/2018 161883.94 134,920,684 134,920,684 147,319,864 9,487,595 3,809,889 4,304,093 45 $ 156,313,210.70 $ (253,513) $ (32,977,558) $ 17,718,540 1/1/2017 12/31/20171/1/2018 12/31/2018 1335.42 295,446 295,446 1,039,380 57,586 28,564 35,843 0 $ 1,089,686.07 $ - $ 125,692 $ 112,569 1/1/2017 12/31/20171/1/2018 12/31/2018 2765.98 501,434 501,434 1,567,616 63,536 36,721 74,659 1 $ 1,593,214.05 $ (332,377) $ 130,032 $ 240,450 1/1/2017 12/31/20171/1/2018 12/31/2018 2735.00 942,643 942,643 588,850 26,717 14,944 73,323 1 $ 557,186.74 $ - $ (276,889) $ 249,287 1/1/2017 12/31/20171/1/2018 12/31/2018 4815.01 1,654,643 1,654,643 690,481 21,056 15,653 128,342 1 $ 598,846.59 $ - $ (130,199) $ 430,790 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/20171/1/2018 12/31/2018 0.00 0 0 0 0 0 0 0 $ - $ - $ - $ - 1/1/2017 12/31/2017

2018 Experience Period (NY statewide experience, base medical policy form + associated riders)


15.3Member months for experience period

15.4Earned premiums for experience period ($)

15.5Standardized earned

premiums for experience period ($)

15.6 Claims Paid in calendar year 2017 on claims incurred during calendar year 2017 -

before any adjustment forfederal risk adjustment, federal reinsurance, risk corridors, state stop-loss


15.6a Claims Paid in calendar year 2018

(during the months of January and February

only) on claims incurred during calendar year 2017 - before any

adjustment for federal risk adjustment, federal

reinsurance, risk corridors, state stop-loss


15.6b All other claim amounts associated with claims incurred during the 2017 calendar year that are not included in

15.6 and 15.6a (i.e., Payments through

February of 2019 plus any remaining IBNR

associated with claims that were incurred during

2017) - before any adjustment for federal

risk adjustment, federal reinsurance, risk

corridors, state stop-loss pools, or commercial

stop-loss payments ($)

15.6c Rx Rebates associated with claims

reported in Columns 15.6and 15.6a (enter as a

positive value) ($)

15.6d Estimated Rx Rebates associated with

claims reported in Column 15.6b or not otherwise included in

15.6c (enter as a positivevalue) ($)

15.7 Total Incurred claims for

calendar year 2017 Net of Rx Rebates ($)


incurred claims for the period due to receipts from state or federal

reinsurance or stop loss pools (enter receipts from

the pool as a negative value) ($)


incurred claims for the period due to receipts

from or payments to the federal risk adjustment

pool (enter receipts as a negative value and

payments to the pool as a positive value) ($)

15.10Administrative expenses

for experience period (including commissions and premium taxes, but excluding federal and

state income taxes) ($)665 $ 454,986 $ 631,066 $ 1,532,918 $ 69,470 $ 43,430 $ 11,780 $ (2) $ 1,634,039.18 $ - $ (573,636) $ 46,293

1,840 $ 1,196,726 $ 1,659,859 $ 1,835,562 $ 72,364 $ 59,765 $ 32,491 $ (5) $ 1,935,205.16 $ - $ (1,316,936) $ 129,357 36 $ 7,039 $ 9,763 $ 3,333 $ 151 $ 111 $ 657 $ (0) $ 2,938.44 $ - $ 14,882 $ 2,210 40 $ 6,360 $ 8,821 $ 3,297 $ 142 $ 105 $ 698 $ (0) $ 2,845.54 $ - $ 13,291 $ 2,271

114 $ 25,903 $ 35,928 $ 4,982 $ 601 $ 140 $ 1,983 $ (0) $ 3,740.05 $ - $ (12,660) $ 6,675 278 $ 63,167 $ 87,613 $ 7,121 $ 278 $ 213 $ 4,875 $ (1) $ 2,737.37 $ - $ 10,964 $ 17,196

2,291 $ 1,225,751 $ 1,700,117 $ 630,921 $ 33,228 $ 20,826 $ 40,491 $ (6) $ 644,490.17 $ - $ 167,510 $ 155,183 623 $ 318,762 $ 442,123 $ 325,165 $ 29,138 $ 14,179 $ 11,063 $ (2) $ 357,420.19 $ - $ (35,242) $ 41,856 88 $ 47,500 $ 65,882 $ 27,016 $ 2,806 $ 1,060 $ 1,555 $ (0) $ 29,327.62 $ - $ (79,290) $ 5,811

3,591 $ 2,628,588 $ 3,645,851 $ 4,661,052 $ 303,832 $ 147,941 $ 63,637 $ (9) $ 5,049,196.94 $ - $ (2,281,294) $ 261,860 5,642 $ 3,913,267 $ 5,427,701 $ 4,040,146 $ 259,100 $ 127,742 $ 99,938 $ (15) $ 4,327,064.47 $ - $ (2,017,068) $ 418,643

136 $ 23,666 $ 32,825 $ 126,542 $ 3,272 $ 4,381 $ 2,413 $ (0) $ 131,782.65 $ - $ (96,032) $ 8,255 138 $ 27,963 $ 38,784 $ 215,600 $ 92,625 $ 12,806 $ 2,465 $ (0) $ 318,566.60 $ - $ (165,503) $ 8,752 278 $ 66,145 $ 91,744 $ 9,308 $ 348 $ 245 $ 5,012 $ (1) $ 4,889.55 $ - $ (19,365) $ 17,329 797 $ 210,630 $ 292,144 $ 40,750 $ 3,095 $ 1,260 $ 14,184 $ (2) $ 30,923.04 $ - $ (2,233) $ 52,184

6,118 $ 3,544,583 $ 4,916,336 $ 3,019,735 $ 154,399 $ 90,344 $ 108,122 $ (16) $ 3,156,370.98 $ - $ (1,541,801) $ 426,741 2,587 $ 1,518,739 $ 2,106,491 $ 1,072,408 $ 47,901 $ 36,140 $ 46,016 $ (7) $ 1,110,439.57 $ - $ (353,787) $ 180,261

962 $ 546,336 $ 757,768 $ 662,758 $ 26,390 $ 42,476 $ 17,097 $ (3) $ 714,529.62 $ - $ (279,679) $ 66,014 68,321 $ 48,031,377 $ 66,619,519 $ 66,294,219 $ 4,025,682 $ 2,142,322 $ 1,210,071 $ (175) $ 71,252,328.07 $ - $ (16,770,807) $ 4,906,230

132,075 $ 89,420,724 $ 124,026,544 $ 119,058,911 $ 6,950,163 $ 3,787,476 $ 2,337,900 $ (338) $ 127,458,987.81 $ - $ (31,277,824) $ 9,713,892 1,735 $ 307,500 $ 426,502 $ 612,031 $ 21,706 $ 18,202 $ 30,901 $ (4) $ 621,042.58 $ - $ 502,531 $ 104,763 3,232 $ 504,477 $ 699,710 $ 1,578,642 $ 186,670 $ 59,933 $ 57,451 $ (8) $ 1,767,802.86 $ - $ 592,558 $ 208,455 3,246 $ 832,603 $ 1,154,821 $ 416,545 $ 13,924 $ 11,715 $ 57,267 $ (8) $ 384,925.13 $ - $ (167,068) $ 198,532

11,781 $ 3,010,727 $ 4,175,878 $ 1,425,546 $ 113,349 $ 52,672 $ 208,247 $ (30) $ 1,383,350.35 $ - $ (922,328) $ 772,033 117,827 $ 64,500,857 $ 89,462,689 $ 50,406,762 $ 2,840,285 $ 1,641,538 $ 2,084,008 $ (300) $ 52,804,877.13 $ - $ 2,053,198 $ 8,233,814 48,901 $ 27,013,973 $ 37,468,380 $ 17,350,998 $ 1,045,198 $ 592,242 $ 867,193 $ (126) $ 18,121,370.62 $ - $ 4,573,609 $ 3,356,206 13,405 $ 7,639,292 $ 10,595,698 $ 6,719,329 $ 434,538 $ 250,738 $ 237,728 $ (35) $ 7,166,911.59 $ - $ 497,798 $ 917,631

12 $ 6,917 $ 9,594 $ 3,669 $ 16 $ 44 $ 165 $ (0) $ 3,564.04 $ - $ 2,084 $ 783 40 $ 49,919 $ 69,237 $ 78,095 $ 5,678 $ 2,545 $ 696 $ (0) $ 85,622.71 $ - $ (41,019) $ 3,287 0 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - 0 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - 0 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - 0 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -

129 $ 113,621 $ 157,592 $ 81,162 $ 1,494 $ 2,368 $ 2,287 $ (0) $ 82,736.66 $ - $ 32,897 $ 9,544 9 $ 7,553 $ 10,476 $ 971 $ 1 $ 20 $ 152 $ (0) $ 840.44 $ - $ 3,106 $ 636 0 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -

46,732 $ 29,224,019 $ 40,533,714 $ 34,592,634 $ 2,119,081 $ 1,127,796 $ 826,275 $ (120) $ 37,013,355.48 $ - $ (6,247,006) $ 3,259,656 54,902 $ 32,453,725 $ 45,013,316 $ 38,375,641 $ 2,304,859 $ 1,222,456 $ 971,612 $ (140) $ 40,931,485.13 $ - $ (9,085,706) $ 3,929,996

673 $ 120,693 $ 167,401 $ 266,074 $ 9,346 $ 7,801 $ 12,090 $ (2) $ 271,132.72 $ - $ 232,222 $ 40,411 816 $ 124,259 $ 172,348 $ 296,724 $ 18,551 $ 9,310 $ 14,555 $ (2) $ 310,032.88 $ - $ 229,636 $ 52,888

1,160 $ 265,174 $ 367,797 $ 108,333 $ 8,747 $ 3,416 $ 20,598 $ (3) $ 99,900.36 $ - $ (29,133) $ 70,306 2,607 $ 590,153 $ 818,542 $ 255,811 $ 30,951 $ 10,889 $ 46,069 $ (7) $ 251,589.17 $ - $ (24,668) $ 172,692

49,157 $ 23,393,086 $ 32,446,211 $ 17,800,102 $ 1,052,360 $ 582,104 $ 868,034 $ (124) $ 18,566,657.09 $ - $ 1,954,298 $ 3,327,881 28,983 $ 14,442,071 $ 20,031,153 $ 8,324,707 $ 647,798 $ 278,746 $ 514,199 $ (75) $ 8,737,127.95 $ - $ 1,572,227 $ 1,948,431 6,570 $ 3,217,834 $ 4,463,136 $ 2,075,472 $ 115,288 $ 66,257 $ 116,344 $ (17) $ 2,140,689.76 $ - $ 140,028 $ 437,615

119,321 $ 80,345,886 $ 111,439,744 $ 107,084,492 $ 6,518,081 $ 3,461,533 $ 2,111,928 $ (306) $ 114,952,483.72 $ - $ (25,870,660) $ 8,474,822 194,500 $ 127,034,360 $ 176,196,658 $ 163,388,356 $ 9,592,164 $ 5,199,984 $ 3,442,636 $ (497) $ 174,738,365.28 $ - $ (43,738,554) $ 14,195,175

2,580 $ 458,897 $ 636,491 $ 1,007,980 $ 34,476 $ 30,495 $ 46,061 $ (7) $ 1,026,896.40 $ - $ 653,602 $ 155,638 4,226 $ 663,059 $ 919,663 $ 2,094,263 $ 297,988 $ 82,154 $ 75,168 $ (11) $ 2,399,247.89 $ - $ 669,982 $ 272,366 4,798 $ 1,189,826 $ 1,650,289 $ 539,168 $ 23,620 $ 15,516 $ 84,861 $ (12) $ 493,455.10 $ - $ (228,225) $ 292,843

15,463 $ 3,874,676 $ 5,374,176 $ 1,729,229 $ 147,673 $ 65,034 $ 273,376 $ (39) $ 1,668,599.94 $ - $ (938,265) $ 1,014,106 175,521 $ 92,777,898 $ 128,682,945 $ 71,938,682 $ 4,081,766 $ 2,337,180 $ 3,102,942 $ (446) $ 75,255,132.03 $ - $ 2,666,102 $ 12,153,163 81,103 $ 43,301,098 $ 60,058,623 $ 27,074,248 $ 1,770,037 $ 921,327 $ 1,438,622 $ (209) $ 28,327,198.77 $ - $ 5,759,912 $ 5,527,390 21,025 $ 11,450,961 $ 15,882,483 $ 9,484,576 $ 579,021 $ 360,531 $ 372,723 $ (54) $ 10,051,458.59 $ - $ 278,858 $ 1,427,071

2017 Experience Period (NY statewide experience, base medical policy form + associated riders)


Exhibit 18 - Index Rate/Plan-Design Level Adjustment Worksheet


SERFF Number: AWLP-131950100Market Segment : Individual

A separate column must be used for each base plan design (i.e., for each separate and distinct 14 digit HIOS ID)

Line # General***ACA Compliant Plans

Only Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10 Plan 111 Product* XXXXXXX HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange 2 Product ID* XXXXXXX 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY0013 Metal Level (or catastrophic)* XXXXXXX Catastrophic Catastrophic Bronze Bronze Bronze Bronze Bronze Bronze Silver Silver Silver4 AV Metal Value (HHS Calculator)* XXXXXXX 0.61792 0.61792 0.63390 0.63390 0.63390 0.63390 0.63390 0.63390 0.71960 0.71960 0.71960 5 AV Pricing Value (total, risk pool experience based)* XXXXXXX 0.29836 0.29836 0.68877 0.68877 0.71730 0.71730 0.28244 0.28244 0.93168 0.97008 0.97008 6 Plan Type* XXXXXXX HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO7 Plan Name* XXXXXXX

pX, Catastrophic, ST, INN,

pX, Catastrophic, ST, INN,

pX, for HSA, Bronze, ST,






pX, Silver, ST, INN,



8 HIOS Plan ID (14 Digits)* XXXXXXX 41046NY0010010 41046NY0010009 41046NY0010002 41046NY0010001 41046NY0010012 41046NY0010011 41046NY0010020 41046NY0010019 41046NY0010003 41046NY0010014 41046NY00100139 Exchange Plan?* XXXXXXX On On On On On On On On On On On

9A 2020 Plan Status (as compared to 2019) XXXXXXX New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan* This field should be the same as used in the Unified Rate Review Template, Worksheet 2

Amounts should be consistent with appropriate categories in Column 14.3 of Exhibit 17Experience Period Index Rate Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10 Plan 11

10 Earned Premiums for Latest Experience Period # 241,526,385.13 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0010A Incurred Claims for Latest Experience Period # 274,151,332.39 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0010B Member-Months for Latest Experience Period # 298,626.08 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0010C Average PMPM Incurred Claims [(10A)/(10B)] = (Initial Index PMPM) 918.04216 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000011 Average Pricing Actuarial Value reflected in experience period 0.9106612 AV Adjusted Experience Period Index Rate PMPM = [(10C) / (11)] 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646

# Amounts should be prior to any adjustments for Federal Risk Adjustment and Healthy NY Stop-Loss Reimbursements, and should be consistent with the amounts reported in Column 14.7 of Exhibit 17 for the relevant market categories.

Market Wide Adjustments to the AV Adjusted Experience Period Index Rate All Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10 Plan 1113 Impact of adjusting experience period data to EHB benefit level ** 1.0000014 Market wide adjustment for changes in provider network ** 0.8830015 Market wide adjustment for fee schedule changes ** 1.0000016 Market wide adjustment for utilization management changes ** 1.0000017 Market wide adjustment for impact on claim costs from quality improvement and cost containment initiatives ** 1.0000018 Claim trend projection factor (midpoint of experience period to mid point of rate applicability period) 1.1639019 Federal Risk Adjustment Program Impact (less than 1.00 to reflect a recovery, more than 1.00 to reflect a payment to the pool) ** 0.7328420 Impact of adjustments due to experience period claim data not being sufficiently credible ** 1.0000021 Adjustment for changes in distribution of risk pool membership by rating regions (i.e., standard rating regions) ** 1.0000022 Change in morbidity not reflected in the experience data that is known and quantifiable at the time of the rate filing ** 1.0000023 Impact of ACA Provision 9010 - Health Insurance Providers Fee ** 1.0278023a Impact of changes in New York State Law that are not reflected in the experience data * 1.0040024 Other 1 (age/gender) 1.0143025 Other 2 (Morbidity) 0.9700026 Other 3 (Grace Period) 1.0024427 Other 4 (Other) 1.0000028 Impact of Market Wide Adjustments (= Product L13 through L27) 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652

** Not Included in Claim Trend Adjustment

Plan Level Adjustments Average - All Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10 Plan 1129 Index Rate - After Marketwide Adjustments 772.7355 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.7354630 Pricing actuarial value (without induced demand factor) # 0.8373 0.66430 0.66430 0.69660 0.69660 0.69660 0.69660 0.28979 0.28979 0.85162 0.85162 0.8516231 Pricing actuarial value (only the induced demand factor) # 1.0532 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.03000 1.03000 1.0300032 Impact of provider network characteristics ## 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000033 Impact of delivery system characteristics ## 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000034 Impact of utilization management practices ## 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000035 Impact on claim costs from quality improvement and cost containment initiatives ## 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000036 Benefits in additional to EHB (greater than 1.00) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000037 Impact of eligibility categories (catastrophic plans only) 0.9873 0.43000 0.43000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000038 Addition of Out of Network Benefit Option (e.g., POS or PPO, if applicable) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000039 Impact of Adjustment for NYS Stop Loss reimbursements on SG HNY 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000040 Impact of Age 26 / Age 29 1.0011 1.00000 1.00000 1.00000 1.00000 1.04100 1.04100 1.00000 1.00000 1.00000 1.04100 1.0410041 Impact of Family Planning / No Family Planning 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000042 Impact of Dental vs No Dental 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000043 Premium Curve Adjustment 0.9819 0.94320 0.94320 0.88210 0.88210 0.88210 0.88210 0.88210 0.88210 0.94304 0.94304 0.9430443a Impact of loss of CSR Funding (A common factor to be applied uniformly to all silver plans only - if applicable) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000043b Rating Region Factor 0.9884 1.01726 1.01726 0.99477 0.99477 0.99477 0.99477 0.99477 0.99477 0.98759 0.98759 0.9875944 Other 1 (Pediatric Dental, Pediatric Vision) 1.0025 1.00280 1.00280 1.00075 1.00075 1.00072 1.00072 1.00190 1.00190 1.00277 1.00266 1.0026645 Other 2 (CLA, Rx Adj, Rx Rebates, Rounding) 1.0317 1.01474 1.01474 1.02925 1.02925 1.02970 1.02970 1.01341 1.01341 1.03211 1.03244 1.0324446 Other 3 (specify) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000047 Impact of Plan Wide Adjustments (= Weighted Average Factor using Line 55a) 0.89407 0.27889 0.27889 0.62961 0.62961 0.65569 0.65569 0.25818 0.25818 0.84550 0.88035 0.88035

# Reflects changes that impact an entire standard population (e.g., cost sharing and other changes that are not based on health status, age, gender or occupation).## Beyond what is reflected in Market Wide adjustments

48a Adjusted Incurred Claims (Excluding Admin Expense and Profit) 206,314,285.36

ExpensesWeighted Average - All

Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10 Plan 1149 Plan Expected Costs 690.88 215.51 215.51 486.52 486.52 506.67 506.67 199.51 199.51 653.35 680.28 680.2850 FIXED EXPENSE: Administrative Costs (excluding Exchange user fees and profits) - to be expressed as a PMPM Amount ### 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000051 VARIABLE EXPENSE: Administrative costs (excluding Exchange user fees and profits) - to be expressed as a percentage ### 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213%52 VARIABLE EXPENSE: Profit/Contribution to surplus margins - to be expressed as a percentage ### 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000%53 Total Expense Load as a percentage of Premium (= [L50 + (L51 + L52) * L56] / L56) 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213%

### The combined factors for Administrative Costs (Fixed and Variable) and Profit/Contribution to surplus margins cannot exceed 18% (equivalent to a factor of 1.2195 ( = 1.00 / 0.82) applied to Line 4 The "FIXED EXPENSE" amount in Line 50 must be entered as a PMPM and "VARIABLE EXPENSE" amounts in Lines 51 and 52 must be entered as a percentage of premium

2019 Premium Rates and Membership All Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10 Plan 1154 2019 PMPM Rates (First Quarter 2019 rates for Small Group)*** 760.18 245.85 245.85 538.88 538.88 561.00 561.00 221.60 221.60 718.50 747.95 747.9555 2019 Members as of 3/31/2019 (The total should tie to the 3/31/2019 Membership Survey Total) 22,167.00 489.00 3.00 4,821.00 23.00 88.00 0.00 93.00 0.00 41.00 171.00 0.0055a 2019 Members as of 3/31/2019 - Only those enrolled in plans that will still be available in 2020 22,167.00 489.00 3.00 4,821.00 23.00 88.00 0.00 93.00 0.00 41.00 171.00 0.00

Calculation of Final 2020 Rates All Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10 Plan 1156 TOTAL PROJECTED INDEX RATE PMPM (= [(L49 + L50) / (1 - L51 - L52)]) 778.13 242.73 242.73 547.97 547.97 570.66 570.66 224.70 224.70 735.86 766.19 766.1957 Percent Change in Premium Rates (= L56 / L54) 2.36% -1.27% -1.27% 1.69% 1.69% 1.72% 1.72% 1.40% 1.40% 2.42% 2.44% 2.44%

*** The information in the "General" Section above should also be completed for any 2019 plans that will no longer be available in 2020.*** The Average PMPM rate for "All Plans" should be used for All Non-ACA Compliant Plans Weighted Average PMPM: 778.13

Difference From Line 56 Col D: 0.00

Overall Average Impact: 2.36% Percentage Difference: 0.0%


DFS

Cross-Out

DFS

Cross-Out

Plan 12 Plan 13 Plan 14 Plan 15 Plan 16 Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 24 Plan 25 Plan 26 Plan 27 Plan 28 Plan 29 HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO On Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange

41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY001 41046NY002 41046NY002 41046NY002Silver Silver Silver Gold Gold Gold Gold Gold Gold Platinum Platinum Platinum Platinum Platinum Platinum Bronze Bronze Bronze

0.71960 0.71960 0.71960 0.80850 0.80850 0.80850 0.80850 0.80850 0.80850 0.88740 0.88740 0.88740 0.88740 0.88740 0.88740 0.63390 0.63390 0.63390 0.38467 0.38467 0.93168 0.48229 1.16518 1.16518 1.21312 0.48229 1.21312 1.41706 1.41706 1.47527 1.47527 0.58793 0.58793 0.28265 0.28265 0.68926

HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMOpX, Silver Child Only, ST,

pX, Silver Child Only, ST,


pX, Gold Child Only, ST,

pX, Gold, ST, INN,

pX, Gold, ST, INN,

pX, Gold, ST, INN,

pX, Gold Child Only, ST,

pX, Gold, ST, INN,

pX, Platinum, ST, INN,




pX, Platinum Child Only,

pX, Platinum Child Only,

pfor HSA, Bronze, ST, INN,



41046NY0010022 41046NY0010021 41046NY0010004 41046NY0010024 41046NY0010006 41046NY0010005 41046NY0010016 41046NY0010023 41046NY0010015 41046NY0010008 41046NY0010007 41046NY0010018 41046NY0010017 41046NY0010026 41046NY0010025 41046NY0020008 41046NY0020007 41046NY0020010On On On On On On On On On On On On On On On Off Off Off

New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan

Plan 12 Plan 13 Plan 14 Plan 15 Plan 16 Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 24 Plan 25 Plan 26 Plan 27 Plan 28 Plan 290.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646

Plan 12 Plan 13 Plan 14 Plan 15 Plan 16 Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 24 Plan 25 Plan 26 Plan 27 Plan 28 Plan 29

0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652

Plan 12 Plan 13 Plan 14 Plan 15 Plan 16 Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 24 Plan 25 Plan 26 Plan 27 Plan 28 Plan 29772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546

0.35427 0.35427 0.85162 0.37886 0.91073 0.91073 0.91073 0.37886 0.91073 0.96911 0.96911 0.96911 0.96911 0.40315 0.40315 0.28999 0.28999 0.697091.03000 1.03000 1.03000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.04100 1.00000 1.04100 1.00000 1.00000 1.04100 1.04100 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.94304 0.94304 0.94304 1.04992 1.04992 1.04992 1.04992 1.04992 1.04992 1.12506 1.12506 1.12506 1.12506 1.12506 1.12506 0.88210 0.88210 0.882101.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.98759 0.98759 0.98759 0.97505 0.97505 0.97505 0.97505 0.97505 0.97505 0.99329 0.99329 0.99329 0.99329 0.99329 0.99329 0.99477 0.99477 0.994771.00692 1.00692 1.00277 1.00727 1.00293 1.00293 1.00281 1.00727 1.00281 1.00345 1.00345 1.00331 1.00331 1.00850 1.00850 1.00190 1.00190 1.000751.02015 1.02015 1.03211 1.02418 1.03377 1.03377 1.03404 1.02418 1.03404 1.03495 1.03495 1.03517 1.03517 1.02702 1.02702 1.01343 1.01343 1.029261.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.34909 0.34909 0.84550 0.43212 1.04397 1.04397 1.08693 0.43212 1.08693 1.29341 1.29341 1.34654 1.34654 0.53663 0.53663 0.25837 0.25837 0.63006

Plan 12 Plan 13 Plan 14 Plan 15 Plan 16 Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 24 Plan 25 Plan 26 Plan 27 Plan 28 Plan 29269.75 269.75 653.35 333.92 806.72 806.72 839.91 333.92 839.91 999.47 999.47 1,040.52 1,040.52 414.67 414.67 199.65 199.65 486.870.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000010.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213%1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000%

11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213%

Plan 12 Plan 13 Plan 14 Plan 15 Plan 16 Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 24 Plan 25 Plan 26 Plan 27 Plan 28 Plan 29296.25 296.25 718.50 363.04 879.64 879.64 915.66 363.04 915.66 1,103.91 1,103.91 1,149.09 1,149.09 456.00 456.00 221.76 221.76 539.2579.00 1.00 8,161.00 59.00 4,073.00 24.00 171.00 0.00 0.00 3,607.00 29.00 148.00 0.00 85.00 1.00 0.00 0.00 0.0079.00 1.00 8,161.00 59.00 4,073.00 24.00 171.00 0.00 0.00 3,607.00 29.00 148.00 0.00 85.00 1.00 0.00 0.00 0.00

Plan 12 Plan 13 Plan 14 Plan 15 Plan 16 Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 24 Plan 25 Plan 26 Plan 27 Plan 28 Plan 29303.82 303.82 735.86 376.09 908.60 908.60 945.99 376.09 945.99 1,125.69 1,125.69 1,171.94 1,171.94 467.04 467.04 224.86 224.86 548.362.56% 2.56% 2.42% 3.59% 3.29% 3.29% 3.31% 3.59% 3.31% 1.97% 1.97% 1.99% 1.99% 2.42% 2.42% 1.40% 1.40% 1.69%


Plan 30 Plan 31 Plan 32 Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 40 Plan 41 Plan 42 Plan 43 Plan 44 Plan 45 Plan 46 Plan 47 HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange HMO Off Exchange

41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002 41046NY002Bronze Bronze Bronze Silver Silver Silver Silver Silver Silver Gold Gold Gold Gold Gold Gold Platinum Platinum Platinum

0.63390 0.63390 0.63390 0.71960 0.71960 0.71960 0.71960 0.71960 0.71960 0.80850 0.80850 0.80850 0.80850 0.80850 0.80850 0.88740 0.88740 0.88740 0.68926 0.71781 0.71781 0.38494 0.38494 0.93233 0.97076 0.97076 0.93233 0.48263 0.48263 1.16600 1.16600 1.21398 1.21398 0.58834 0.58834 1.41806

HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMOpfor HSA, Bronze, ST, INN,



pSilver Child Only, ST,


pSilver, ST, INN, Pediatric




pGold Child Only, ST, INN,

pGold Child Only, ST, INN,

pGold, ST, INN, Pediatric




pPlatinum Child Only, ST,


pPlatinum, ST, INN,

41046NY0020009 41046NY0020011 41046NY0020012 41046NY0020006 41046NY0020005 41046NY0020014 41046NY0020015 41046NY0020016 41046NY0020013 41046NY0020002 41046NY0020001 41046NY0020018 41046NY0020017 41046NY0020020 41046NY0020019 41046NY0020004 41046NY0020003 41046NY0020022Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off

New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan

Plan 30 Plan 31 Plan 32 Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 40 Plan 41 Plan 42 Plan 43 Plan 44 Plan 45 Plan 46 Plan 470.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646 1,008.10646


0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652 0.76652


0.69709 0.69709 0.69709 0.35452 0.35452 0.85221 0.85221 0.85221 0.85221 0.37913 0.37913 0.91137 0.91137 0.91137 0.91137 0.40343 0.40343 0.969791.00000 1.00000 1.00000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.15000 1.15000 1.150001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.04100 1.04100 1.00000 1.00000 1.00000 1.04100 1.04100 1.00000 1.00000 1.00000 1.00000 1.00000 1.04100 1.04100 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.88210 0.88210 0.88210 0.94304 0.94304 0.94304 0.94304 0.94304 0.94304 1.04992 1.04992 1.04992 1.04992 1.04992 1.04992 1.12506 1.12506 1.125061.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.99477 0.99477 0.99477 0.98759 0.98759 0.98759 0.98759 0.98759 0.98759 0.97505 0.97505 0.97505 0.97505 0.97505 0.97505 0.99329 0.99329 0.993291.00075 1.00072 1.00072 1.00691 1.00691 1.00277 1.00265 1.00265 1.00277 1.00726 1.00726 1.00293 1.00293 1.00281 1.00281 1.00850 1.00850 1.003451.02926 1.02970 1.02970 1.02016 1.02016 1.03211 1.03244 1.03244 1.03211 1.02419 1.02419 1.03378 1.03378 1.03404 1.03404 1.02703 1.02703 1.034951.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.63006 0.65615 0.65615 0.34934 0.34934 0.84609 0.88097 0.88097 0.84609 0.43243 0.43243 1.04471 1.04471 1.08769 1.08769 0.53700 0.53700 1.29432

Plan 30 Plan 31 Plan 32 Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 40 Plan 41 Plan 42 Plan 43 Plan 44 Plan 45 Plan 46 Plan 47486.87 507.03 507.03 269.94 269.94 653.81 680.75 680.75 653.81 334.15 334.15 807.28 807.28 840.50 840.50 414.96 414.96 1,000.170.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000010.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213% 10.213%1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000% 1.000%

11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213% 11.213%

Plan 30 Plan 31 Plan 32 Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 40 Plan 41 Plan 42 Plan 43 Plan 44 Plan 45 Plan 46 Plan 47539.25 561.39 561.39 296.46 296.46 719.01 748.47 748.47 719.01 363.30 363.30 880.25 880.25 916.30 916.30 456.31 456.31 1,104.690.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Plan 30 Plan 31 Plan 32 Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 40 Plan 41 Plan 42 Plan 43 Plan 44 Plan 45 Plan 46 Plan 47548.36 571.07 571.07 304.04 304.04 736.38 766.73 766.73 736.38 376.36 376.36 909.24 909.24 946.65 946.65 467.37 467.37 1,126.481.69% 1.72% 1.72% 2.56% 2.56% 2.42% 2.44% 2.44% 2.42% 3.59% 3.59% 3.29% 3.29% 3.31% 3.31% 2.42% 2.42% 1.97%


Plan 48 Plan 49 Plan 50 Plan 51 Plan 52 Plan 53 Plan 54 Plan 55 Plan 56 Plan 57 Plan 58 Plan 59 Plan 60 Plan 61 Plan 62 Plan 63 Plan 64 Plan 65 HMO Off Exchange HMO Off Exchange HMO Off Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange

41046NY002 41046NY002 41046NY002 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054Platinum Platinum Platinum Catastrophic Catastrophic Bronze Bronze Bronze Bronze Bronze Bronze Silver Silver Silver Silver Silver Silver Gold

0.88740 0.88740 0.88740 0.61302 0.61302 0.60870 0.60870 0.60870 0.60870 0.60870 0.60870 0.70300 0.70300 0.70300 0.70300 0.70300 0.70300 0.78620 1.41806 1.47631 1.47631 - - - - - - - - - - - - - - -

HMO HMO HMO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPOpPlatinum, ST, INN,

pPlatinum, ST, INN,

pPlatinum, ST, INN,

pCatastrophic, ST, INN,

pCatastrophic, ST, INN,

pHSA, Bronze, ST, INN,












pST, INN, Pediatric Dental,

41046NY0020021 41046NY0020024 41046NY0020023 44113NY0540108 44113NY0540109 44113NY0540100 44113NY0540110 44113NY0540118 44113NY0540101 44113NY0540111 44113NY0540119 44113NY0540102 44113NY0540112 44113NY0540120 44113NY0540103 44113NY0540113 44113NY0540121 44113NY0540104Off Off Off On On On On On On On On On On On On On On On

New Plan New Plan New Plan Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered

Plan 48 Plan 49 Plan 50 Plan 51 Plan 52 Plan 53 Plan 54 Plan 55 Plan 56 Plan 57 Plan 58 Plan 59 Plan 60 Plan 61 Plan 62 Plan 63 Plan 64 Plan 650.00 0.00 0.00 2,577,079.54 20,206.32 36,480,044.65 884,963.16 107,595.51 158,209.92 1,900.26 0.00 80,723,454.67 2,358,250.75 177,966.76 206,644.04 0.00 0.00 54,039,787.850.00 0.00 0.00 1,155,683.74 349.59 15,196,682.31 549,917.97 388,060.87 29,892.78 85.34 0.00 66,909,100.86 1,408,499.14 186,278.88 285,710.93 0.00 0.00 64,495,236.250.00 0.00 0.00 7,485.01 65.00 57,883.75 1,780.00 779.66 247.00 4.00 0.00 104,885.11 3,677.00 1,046.79 267.00 0.00 0.00 59,677.96

0.00000 0.00000 0.00000 154.39976 5.37828 262.53797 308.94268 497.73089 121.02339 21.33441 0.00000 637.92755 383.05661 177.95249 1070.07840 0.00000 0.00000 1080.72120

1,008.10646 1,008.10646 1,008.10646


0.76652 0.76652 0.76652


0.96979 0.96979 0.96979 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.15000 1.15000 1.15000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.04100 1.04100 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.12506 1.12506 1.12506 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.99329 0.99329 0.99329 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00345 1.00331 1.00331 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.03495 1.03517 1.03517 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.29432 1.34749 1.34749

Plan 48 Plan 49 Plan 50 Plan 51 Plan 52 Plan 53 Plan 54 Plan 55 Plan 56 Plan 57 Plan 58 Plan 59 Plan 60 Plan 61 Plan 62 Plan 63 Plan 64 Plan 651,000.17 1,041.25 1,041.250.00000 0.00000 0.0000010.213% 10.213% 10.213%1.000% 1.000% 1.000%

11.213% 11.213% 11.213%

Plan 48 Plan 49 Plan 50 Plan 51 Plan 52 Plan 53 Plan 54 Plan 55 Plan 56 Plan 57 Plan 58 Plan 59 Plan 60 Plan 61 Plan 62 Plan 63 Plan 64 Plan 651,104.69 1,149.90 1,149.90

0.00 0.00 0.000.00 0.00 0.00

Plan 48 Plan 49 Plan 50 Plan 51 Plan 52 Plan 53 Plan 54 Plan 55 Plan 56 Plan 57 Plan 58 Plan 59 Plan 60 Plan 61 Plan 62 Plan 63 Plan 64 Plan 651,126.48 1,172.76 1,172.761.97% 1.99% 1.99%


Plan 66 Plan 67 Plan 68 Plan 69 Plan 70 Plan 71 Plan 72 Plan 73 Plan 74 Plan 75 Plan 76 Plan 77 Plan 78 Plan 79 Plan 80 Plan 81 Plan 82 Plan 83 EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange

44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY054 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056Gold Gold Gold Gold Gold Platinum Platinum Platinum Platinum Platinum Platinum Bronze Bronze Bronze Bronze Bronze Bronze Silver

0.78620 0.78620 0.78620 0.78620 0.78620 0.87230 0.87230 0.87230 0.87230 0.87230 0.87230 0.60870 0.60870 0.60870 0.60870 0.60870 0.60870 0.70300 - - - - - - - - - - - - - - - - - -

EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPOpST, INN, Pediatric Dental,

pChild Only, ST, INN,




pPlatinum, ST, INN,

pPlatinum, ST, INN,


pPlatinum, ST, INN,

pPlatinum, ST, INN,









44113NY0540114 44113NY0540122 44113NY0540105 44113NY0540115 44113NY0540123 44113NY0540106 44113NY0540116 44113NY0540124 44113NY0540107 44113NY0540117 44113NY0540125 44113NY0560106 44113NY0560108 44113NY0560110 44113NY0560107 44113NY0560109 44113NY0560111 44113NY0560104On On On On On On On On On On On Off Off Off Off Off Off Off

Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered

Plan 66 Plan 67 Plan 68 Plan 69 Plan 70 Plan 71 Plan 72 Plan 73 Plan 74 Plan 75 Plan 76 Plan 77 Plan 78 Plan 79 Plan 80 Plan 81 Plan 82 Plan 831,775,138.25 189,162.65 265,634.08 0.00 0.00 58,658,252.73 1,895,839.34 322,155.01 349,736.52 0.00 0.00 0.00 20,413.49 0.00 0.00 0.00 0.00 0.001,636,138.51 549,749.23 189,121.44 0.00 0.00 115,610,825.72 2,506,696.02 1,558,811.13 1,023,912.71 0.00 0.00 0.00 2,372.15 0.00 0.00 0.00 0.00 0.00

2,566.86 916.86 316.00 0.00 0.00 52,755.99 2,134.00 1,358.09 336.00 0.00 0.00 0.00 28.00 0.00 0.00 0.00 0.00 0.00637.40855 599.59997 598.48556 0.00000 0.00000 2191.42558 1174.64668 1147.79664 3047.35924 0.00000 0.00000 0.00000 84.71969 0.00000 0.00000 0.00000 0.00000 0.00000



1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000





Plan 84 Plan 85 Plan 86 Plan 87 Plan 88 Plan 89 Plan 90 Plan 91 Plan 92 Plan 93 Plan 94 Plan 95 Plan 96 Plan 97 Plan 98 Plan 99 Plan 100 EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange EPO On Exchange

44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056 44113NY056Silver Silver Silver Silver Silver Gold Gold Gold Gold Gold Gold Platinum Platinum Platinum Platinum Platinum Platinum

0.70300 0.70300 0.70300 0.70300 0.70300 0.78620 0.78620 0.78620 0.78620 0.78620 0.78620 0.87230 0.87230 0.87230 0.87230 0.87230 0.87230 - - - - - - - - - - - - - - - - -

EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPOpST, INN, Pediatric Dental,

















44113NY0560112 44113NY0560114 44113NY0560105 44113NY0560113 44113NY0560115 44113NY0560100 44113NY0560116 44113NY0560118 44113NY0560101 44113NY0560117 44113NY0560119 44113NY0560102 44113NY0560120 44113NY0560122 44113NY0560103 44113NY0560121 44113NY0560123Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off

Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered Not Offered

Plan 84 Plan 85 Plan 86 Plan 87 Plan 88 Plan 89 Plan 90 Plan 91 Plan 92 Plan 93 Plan 94 Plan 95 Plan 96 Plan 97 Plan 98 Plan 99 Plan 100108,191.05 27,824.70 0.00 0.00 0.00 0.00 55,962.61 0.00 0.00 0.00 0.00 0.00 108,028.07 13,943.21 0.00 0.00 0.0034,813.86 21,986.51 0.00 0.00 0.00 0.00 21,059.31 0.00 0.00 0.00 0.00 0.00 291,852.67 98,494.46 0.00 0.00 0.00

175.00 72.00 0.00 0.00 0.00 0.00 63.00 0.00 0.00 0.00 0.00 0.00 94.00 12.00 0.00 0.00 0.00198.93635 305.36824 0.00000 0.00000 0.00000 0.00000 334.27480 0.00000 0.00000 0.00000 0.00000 0.00000 3104.81563 8207.87192 0.00000 0.00000 0.00000

Plan 84 Plan 85 Plan 86 Plan 87 Plan 88 Plan 89 Plan 90 Plan 91 Plan 92 Plan 93 Plan 94 Plan 95 Plan 96 Plan 97 Plan 98 Plan 99 Plan 100

Plan 84 Plan 85 Plan 86 Plan 87 Plan 88 Plan 89 Plan 90 Plan 91 Plan 92 Plan 93 Plan 94 Plan 95 Plan 96 Plan 97 Plan 98 Plan 99 Plan 100772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546 772.73546

1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000





Exhibit 18 Supplement


SERFF Number: AWLP-131950100Market Segment : Individual

Expense Data - Individual 2020 Expected 2019 Expected 2018 Expected 2017 Expected 2018 Actual 2017 ActualPeriod assumed - beginning date 1/1/2020 1/1/2019 1/1/2018 1/1/2017 1/1/2018 1/1/2017

Period assumed - ending date 12/31/2020 12/31/2019 12/31/2018 12/31/2017 12/31/2018 12/31/2017Average annual claim trend assumed 7.88% 11.50% 0.00% 0.00% 0.00% 0.00%

Regulatory authority licenses and fees, including New York State 206 assessment expenses - as a % of gross premium 0.71% 0.78% 0.00% 0.00% 0.00% 0.00%Administrative expenses for activities that improve health care quality as defined in the NAIC Annual Statement Supplement Health Care Exhibit - as a % of gross premium 0.95% 0.76% 0.00% 0.00% 0.00% 0.00%

Commissions and broker fees - as a % of gross premium 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%Premium Taxes - as a % of gross premium 2.00% 2.00% 0.00% 0.00% 0.00% 0.00%

Other state and federal taxes and assessments (other than income taxes and covered lives assessment) - as a % of gross premium 2.78% 0.00% 0.00% 0.00% 0.00% 0.00%Other administrative expenses - as a % of gross premium 6.29% 5.08% 0.00% 0.00% 0.00% 0.00%

Subtotal 12.721% 8.628% 0.000% 0.000% 0.000% 0.000%

After tax underwriting margin (profit/contribution to surplus) - as a % of gross premium 0.73% 1.19% 0.00% 0.00% 0.00% 0.00%State income tax component - as a % of gross premium 0.08% 0.00% 0.00% 0.00% 0.00% 0.00%

State income tax rate assumed (e.g. 3%) 8.19% 0.00% 0.00% 0.00% 0.00% 0.00%Federal income tax component - as a % of gross premium 0.19% 0.32% 0.00% 0.00% 0.00% 0.00%

Federal income tax rate assumed (e.g. 30%) 19.28% 21.00% 0.00% 0.00% 0.00% 0.00%Reduction for assumed net investment income - as a % of gross premium (enter as a negative value) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Subtotal 1.000% 1.500% 0.000% 0.000% 0.000% 0.000%

Total 13.721% 10.128% 0.000% 0.000% 0.000% 0.000%

Exhibit 18 Supplement Last Updated ‐ 4/10/2018 7

DFS

Cross-Out

DFS

Cross-Out

EXHIBIT 19 - SUMMARY OF AVERAGE CLAIM TREND AND ADMINISTRATIVE EXPENSES AND PROFIT MARGIN

Company Name: Empire Healthchoice Assurance HealthPlus HP, LLCNAIC Code: 55093 16574SERFF Number: AWLP-131950100 Market Segment: Individual

1 Complete a separate ROW for each Metal Level/Product for all ACA compliant business written or renewed on or after 1/1/2016 in the relevant market for which the Company had business in-force during the applicable experience period. • Information should be for all the benefits included in that plan design including any riders (medical, drugs, etc.). • Enter in column 1 the Metal Tier level. • Enter in column 2 the plan designation as to On/Off Plan and Std/Non Standard Plan. • Enter in column 3 the Estimated Membership as of a recent date mm/dd/yyy; enter the date in column heading. • Append additional rows to the end of the existing rows as needed. Only use the first tab for data entry.

2 The average claim trend is the average annualized claim trend that is used in the applicable rate adjustment filing to project the source data forward to the applicable rating period (e.g. 10.0%).

3 Enter the required information for the new rate period included in this rate adjustment filing. This refers to the various expense components and profit margin included in the requested rates and the average annual claim trend assumed.

4 Enter the corresponding information requested for the immediately prior rate and form filing. This refers to the various expense components in the requested rates submitted for the immediately prior rate and form filing and the average claim trend assumed. If there is no immediately prior rate and form filing, enter the data from the initial rate and form filing.

5 ACA Fees that may be applicable are to be entered in columns 6.1 and 16.1.6 This exhibit must be submitted as an Excel file and as a PDF file.

Exhibit 19 ‐ Instructions Updated by DFS 3/14/2018 1

DFS

Cross-Out

DFS

Cross-Out

A. Company Name B. NAIC Code C. SERFF Number D. Market1.

Metal Level

2. On/Off Exchange Designation and

Standard/Non Std

3. Estimated

Membership as of 03/31/2019

4.1 Period assumed -

beginning date (mm/dd/yy)

4.2Period assumed -

ending date (mm/dd/yy)

5. Average annual

claim trend assumed

6.1 Regulatory authoritylicenses and fees, including New York

State 206 assessment

expenses - as a % of gross premium

6.2 Administrative expenses for activities that

improve health care quality as defined in

the NAIC Annual Statement

Supplement Health Care Exhibit - as a

% of gross premium

6.3Commissions and

broker fees - as a %of gross premium

6.4Premium Taxes - as

a % of gross premium

6.5 Other state and

federal taxes and assessments (other than income taxes and covered lives

assessment) - as a % of gross premium

6.6 Other administrativeexpenses - as a % of gross premium

6.7Subtotal columns 6.1 through 6.6

7. After tax

underwriting margin (profit/contribution

to surplus) - as a % of gross premium

8. State income tax

component - as a %of gross premium

8.1 State income tax

rate assumed (e.g. 3%)

9.Federal income tax component - as a %of gross premium

9.1Federal income tax rate assumed (e.g.

30%)

10.Reduction for assumed net

investment income -as a % of gross

premium (enter as anegative value)

11.Subtotal columns

6.7 + 7 + 8 + 9 + 10Empire Healthchoice 55093 AWLP‐131950100 Individual Platinum Standard On Exchange 3,021 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.27% 12.70% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.70%Empire Healthchoice 55093 AWLP‐131950100 Individual Gold Standard On Exchange 3,632 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.28% 12.71% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.71%Empire Healthchoice 55093 AWLP‐131950100 Individual Silver Standard On Exchange 7,370 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.29% 12.73% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.73%Empire Healthchoice 55093 AWLP‐131950100 Individual Bronze Standard On Exchange 4,287 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.31% 12.74% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.74%Empire Healthchoice 55093 AWLP‐131950100 Individual Catastrophic Standard On Exchange 408 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.42% 12.85% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.85%Empire Healthchoice 55093 AWLP‐131950100 Individual Platinum Standard Off Exchange 849 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.27% 12.70% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.70%Empire Healthchoice 55093 AWLP‐131950100 Individual Gold Standard Off Exchange 695 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.28% 12.71% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.71%Empire Healthchoice 55093 AWLP‐131950100 Individual Silver Standard Off Exchange 1,083 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.29% 12.73% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.73%Empire Healthchoice 55093 AWLP‐131950100 Individual Bronze Standard Off Exchange 738 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.31% 12.74% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.74%Empire Healthchoice 55093 AWLP‐131950100 Individual Catastrophic Standard On Exchange 84 1/1/2020 12/31/2020 7.88% 0.71% 0.95% 0.00% 2.00% 2.78% 6.42% 12.85% 0.73% 0.08% 8.19% 0.19% 19.28% 0.00% 13.85%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%Empire Healthchoice 55093 AWLP‐131950100 Individual 0.00% 0.00%

General Information For the rate period included in this rate adjustment filing


14.1 Period assumed -

beginning date (mm/dd/yy)

14.2Period assumed -

ending date (mm/dd/yy)

15. Average annual

claim trend assumed

16.1 Regulatory authoritylicenses and fees, including New York

State 206 assessment

expenses - as a % of gross premium

16.2 Administrative expenses for activities that

improve health care quality as defined in

the NAIC Annual Statement

Supplement Health Care Exhibit - as a

% of gross premium

16.3Commissions and

broker fees - as a %of gross premium

16.4Premium Taxes - as

a % of gross premium

16.5 Other state and

federal taxes and assessments (other than income taxes and covered lives

assessment) - as a % of gross premium

16.6 Other administrativeexpenses - as a % of gross premium

16.7Subtotal columns 16.1 through 16.6

17 After tax

underwriting margin (profit/contribution

to surplus) - as a % of gross premium

18State income tax

component - as a %of gross premium

18.1 State income tax

rate assumed (e.g. 3%)

19Federal income tax component - as a %of gross premium

19.1Federal income tax rate assumed (e.g.

30%)

20Reduction for assumed net

investment income -as a % of gross

premium (enter as anegative value)

21Subtotal columns

16.7 + 17 + 18 + 19 +20

1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.07% 8.62% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.12%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.08% 8.62% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.12%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.09% 8.63% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.13%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.10% 8.65% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.15%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.19% 8.73% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.23%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.07% 8.62% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.12%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.08% 8.62% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.12%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.09% 8.63% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.13%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.10% 8.65% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.15%1/1/2019 12/31/2019 11.50% 0.78% 0.76% 0.00% 2.00% 0.00% 5.19% 8.73% 1.19% 0.00% 0.00% 0.32% 21.00% 0.00% 10.23%

0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%0.00% 0.00%

For the rate period included in the prior rate and form filing


EXHIBIT 23: SUMMARY OF REQUESTED 2020 PREMIUM RATES

Company Name: Empire Healthchoice Assurance HealthPlus HP, LLCNAIC Code: 55093 16574SERFF Number: AWLP-131950100Market Segment: Individual

1 Purpose of this Exhibit is to provide the actual distribution of all base Premium Rates for all Metal Levels and Regions.2 Premium rates and member months are required for Calendar Years 2017 - 2020 for Individual (Individual only) and First Quarter 2017 - 2020 for Small Group (Employee only).3 Membership must be consistent with the applicable DFS survey as of 3/31 for each of the respective years.4 Premium rates must be based on the subscriber (Individual) or employee (Small Group) rate and should not be a PMPM amount.5 Premiums should be reported for all plan variations (e.g., if the Company has different rates when family planning, pediatric dental, domestic partner, or age 29 coverage are added, etc.).6 Additional guidance is provided in the various headings of the Exhibit.7 This exhibit must be submitted as an Excel and as a PDF file.8 The "PNDS Identifier" represents the code used in the Department of Health's PNDS system to identify the specific provider network associated with a particular plan. 9 The "Company Network Identifier" represents the specific code used by the Company to identify each distinct provider network used by the Company.

Exhibit 23 ‐ Instructions Updated by DFS 3/14/2018 1

DFS

Cross-Out

DFS

Cross-Out

1. Company Name 2. NAIC Code

3. SERFF Number 4. Market

5. Current HIOS ID (14 Digits)

6. Previous HIOS ID (14 Digits)

7. Metal Level or Catastrophic

8. Exchange ["On"/"Off"]

9. Plan Type [Std or Non Std]

10.Limiting Child

Age? (26 or 30)

11. Domestic Partner

Coverage Included? (yes,

no)

12. Family

Planning Coverage? (included, excluded)

13. Pediatric

Dental Coverage

Included? (yes, no)

14. Out of Network

Benefits? (yes, no)

15. Includes

Benefits in Addition to

EHB? (yes, no)

16. Healthy New

York (yes, no)

17. Child-Only

Plan (yes, no)

18. Tiered Network Plan (yes, no)

19. HSA Plan (yes,

no)20.

PNDS Identifier

21. Company Network Identifier

Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010010 NA Catastrophic On Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1

Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010009 NA Catastrophic On Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1

Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010002 NA Bronze On Std 26 Yes Included Yes No Yes No No No Yes 0128 NYNEP1

Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010001 NA Bronze On Std 26 Yes Included Yes No Yes No No No Yes 0128 NYNEP1

Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010012 NA Bronze On Std 30 Yes Included Yes No Yes No No No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010011 NA Bronze On Std 30 Yes Included Yes No Yes No No No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010020 NA Bronze On Std 26 No Included Yes No Yes No Yes No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010019 NA Bronze On Std 26 No Included Yes No Yes No Yes No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010003 NA Silver On Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010014 NA Silver On Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010013 NA Silver On Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010022 NA Silver On Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010021 NA Silver On Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010004 NA Silver On Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010024 NA Gold On Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010006 NA Gold On Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010005 NA Gold On Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010016 NA Gold On Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010023 NA Gold On Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010015 NA Gold On Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010008 NA Platinum On Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010007 NA Platinum On Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010018 NA Platinum On Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010017 NA Platinum On Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010026 NA Platinum On Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0010025 NA Platinum On Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020008 NA Bronze Off Std 26 No Included Yes No Yes No Yes No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020007 NA Bronze Off Std 26 No Included Yes No Yes No Yes No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020010 NA Bronze Off Std 26 Yes Included Yes No Yes No No No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020009 NA Bronze Off Std 26 Yes Included Yes No Yes No No No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020011 NA Bronze Off Std 30 Yes Included Yes No Yes No No No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020012 NA Bronze Off Std 30 Yes Included Yes No Yes No No No Yes 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020006 NA Silver Off Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020005 NA Silver Off Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020014 NA Silver Off Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020015 NA Silver Off Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020016 NA Silver Off Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020013 NA Silver Off Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020002 NA Gold Off Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020001 NA Gold Off Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020018 NA Gold Off Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020017 NA Gold Off Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020020 NA Gold Off Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020019 NA Gold Off Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020004 NA Platinum Off Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020003 NA Platinum Off Std 26 No Included Yes No Yes No Yes No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020022 NA Platinum Off Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020021 NA Platinum Off Std 26 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020024 NA Platinum Off Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual 41046NY0020023 NA Platinum Off Std 30 Yes Included Yes No Yes No No No No 0128 NYNEP1Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540134 Catastrophic On Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540135 Catastrophic On Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540126 Bronze On Std 26 Yes Included Yes No Yes No No No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540136 Bronze On Std 30 Yes Included Yes No Yes No No No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540144 Bronze On Std 26 No Included Yes No Yes No Yes No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540127 Bronze On Std 26 Yes Included Yes No Yes No No No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540137 Bronze On Std 30 Yes Included Yes No Yes No No No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540145 Bronze On Std 26 No Included Yes No Yes No Yes No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540128 Silver On Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540138 Silver On Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540146 Silver On Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540129 Silver On Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540139 Silver On Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540147 Silver On Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540130 Gold On Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540140 Gold On Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540148 Gold On Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540131 Gold On Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540141 Gold On Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540149 Gold On Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540132 Platinum On Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540142 Platinum On Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540150 Platinum On Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540133 Platinum On Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540143 Platinum On Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0540151 Platinum On Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560160 Bronze Off Std 26 No Included Yes No Yes No Yes No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560162 Bronze Off Std 26 Yes Included Yes No Yes No No No Yes 0057 NYN003

PLAN INFORMATION


Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560164 Bronze Off Std 30 Yes Included Yes No Yes No No No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560161 Bronze Off Std 26 No Included Yes No Yes No Yes No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560163 Bronze Off Std 26 Yes Included Yes No Yes No No No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560165 Bronze Off Std 30 Yes Included Yes No Yes No No No Yes 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560158 Silver Off Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560166 Silver Off Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560168 Silver Off Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560159 Silver Off Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560167 Silver Off Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560169 Silver Off Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560154 Gold Off Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560170 Gold Off Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560172 Gold Off Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560155 Gold Off Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560171 Gold Off Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560173 Gold Off Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560156 Platinum Off Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560174 Platinum Off Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560176 Platinum Off Std 30 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560157 Platinum Off Std 26 No Included Yes No Yes No Yes No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560175 Platinum Off Std 26 Yes Included Yes No Yes No No No No 0057 NYN003Empire Healthchoic55093 AWLP-131950100 Individual NA 44113NY0560177 Platinum Off Std 30 Yes Included Yes No Yes No No No No 0057 NYN003


Region 1 - 2017 Rate (Albany)

Region 2 - 2017 Rate (Buffalo)

Region 3 - 2017 Rate (Mid-Hudson)

Region 4 - 2017 Rate (New York)

Region 5 - 2017 Rate (Rochester)

Region 6 - 2017 Rate (Syracuse)

Region 7 - 2017 Rate (Utica)

Region 8 - 2017 Rate (Long

Island)Region 1 - 2017 MMs (Albany)

Region 2 - 2017 MMs (Buffalo)

Region 3 - 2017 MMs (Mid-Hudson)

Region 4 - 2017 MMs (New York)

Region 5 - 2017 MMs (Rochester)

Region 6 - 2017 MMs (Syracuse)

Region 7 - 2017 MMs (Utica)

Region 8 - 2017 MMs (Long

Island)Region 1 - 2018 Rate (Albany)




2017 PREMIUM RATES 2017 MEMBER MONTHS 2018 PREM






Island)Region 1 - 2018 MMs (Albany)

Region 2 - 2018 MMs (Buffalo)

Region 3 - 2018 MMs (Mid-Hudson)

Region 4 - 2018 MMs (New York)

Region 5 - 2018 MMs (Rochester)

Region 6 - 2018 MMs (Syracuse)

Region 7 - 2018 MMs (Utica)

Region 8 - 2018 MMs (Long









Island)

251.13 296.21 295.25 236.26251.13 416.38570.13 672.45 670.27 536.35593.54 700.07 697.80 558.38234.45 276.53 275.64 220.56570.13 945.27593.54 984.09234.45 388.72770.19 908.41 905.47 724.56801.79 945.68 942.62 754.29317.54 374.53 373.32 298.73770.19 1,276.97801.79 1,329.36317.54 526.49962.58 1,135.33 1,131.65 905.55

1,002.05 1,181.89 1,178.06 942.69397.32 468.63 467.11 373.78962.58 1,595.95

1,002.05 1,661.40397.32 658.75

1,171.03 1,381.20 1,376.72 1,101.651,218.89 1,437.65 1,432.99 1,146.68

483.72 570.54 568.69 455.071,171.03 1,941.561,218.89 2,020.92

483.72 802.01234.66 276.78 275.88 220.76570.54 672.94 670.76 536.74

IUM RATES 2018 MEMBER MONTHS 2019 PREMIUM RATES


593.96 700.56 698.28 558.77234.66 389.07570.54 945.96593.96 984.78317.75 374.78 373.56 298.93770.70 909.03 906.08 725.05802.30 946.30 943.23 754.77317.75 526.83770.70 1,277.82802.30 1,330.22397.53 468.87 467.35 373.98963.30 1,136.19 1,132.51 906.24

1,002.78 1,182.75 1,178.91 943.37397.53 659.10963.30 1,597.15

1,002.78 1,662.60484.03 570.91 569.05 455.36

1,171.86 1,382.17 1,377.69 1,102.431,219.82 1,438.75 1,434.08 1,147.56

484.03 802.531,171.86 1,942.931,219.82 2,022.46


Region 1 - 2019 Members as of

3/31/2019 (Albany)


3/31/2019 (Buffalo)

Region 3 - 2019 Members as of 3/31/2019 (Mid-

Hudson)

Region 4 - 2019 Members as of 3/31/2019 (New

York)


3/31/2019 (Rochester)


3/31/2019 (Syracuse)


3/31/2019 (Utica)

Region 8 - 2019 Members as of 3/31/2019 (Long









Island)


3/31/2019 (Albany)


3/31/2019 (Buffalo)


Hudson)


York)

243.67 287.41 286.50 252.12

243.67 404.02

562.41 663.36 661.27 581.92

562.41 932.50

585.75 690.89 688.71 606.07585.75 971.20230.66 272.06 271.20 238.66230.66 382.44760.78 1,261.40792.18 934.36 931.42 819.65792.18 1,313.45314.10 370.48 369.31 325.00314.10 520.80760.78 897.33 894.50 787.17393.81 464.49 463.03 407.47951.42 1,122.19 1,118.65 984.42951.42 1,577.49990.63 1,168.43 1,164.75 1,024.98393.81 652.95990.63 1,642.49

1,157.11 1,364.80 1,360.50 1,197.241,157.11 1,918.531,204.69 1,420.92 1,416.44 1,246.471,204.69 1,997.42

480.10 566.28 564.49 496.75480.10 796.03230.82 272.25 271.39 238.83230.82 382.71562.82 663.84 661.74 582.34562.82 933.17586.16 971.88586.16 691.37 689.19 606.49314.35 370.77 369.60 325.25314.35 521.20761.35 898.00 895.17 787.75792.66 1,314.26792.66 934.93 931.99 820.15761.35 1,262.35394.14 464.88 463.41 407.80394.14 653.49952.16 1,123.05 1,119.52 985.18952.16 1,578.71991.28 1,169.20 1,165.51 1,025.66991.28 1,643.57480.43 566.66 564.87 497.09480.43 796.57

1,157.93 1,365.76 1,361.45 1,198.081,157.93 1,919.881,205.51 1,421.88 1,417.40 1,247.311,205.51 1,998.77

12.00 374.00 103.00 12.00 374.003.00 3.00

89.00 3,004.00 1,728.00 89.00 3,004.0047.00 41.00 47.00

1.00 78.00 14.00 1.00 78.0023.00 23.00

155.00 4,565.00 3,441.00 155.00 4,565.002.00 82.00 87.00 2.00 82.001.00 50.00 28.00 1.00 50.00

41.00 41.00

1.00 1.0075.00 1,955.00 2,043.00 75.00 1,955.00

52.00 119.00 52.001.00 37.00 21.00 1.00 37.00

24.00 24.00

82.00 2,186.00 1,339.00 82.00 2,186.003.00 80.00 65.00 3.00 80.002.00 61.00 22.00 2.00 61.00

29.00 29.00

1.00 1.00

2019 MEMBERS (per DFS Membership Survey) 2020 PREMIUM RATES

2019 MEMBERS (Should be consistent with DFS Membership Survey) ‐ Only

offered in 2020







3/31/2019 (Utica)


Island)


3/31/2019 (Albany)


3/31/2019 (Buffalo)


Hudson)


York)






3/31/2019 (Utica)


Island)

103.00

1,728.0041.0014.00

3,441.0087.0028.00

2,043.00119.0021.00

1,339.0065.0022.00

those members currently enrolled in 2019 plans that will continue to be 2019 MEMBERS ‐ Only those members currently enrolled in 2019 plans Including plans that will be discontinued in 2020 ***** Columns CH ‐ CO

apply to SMALL GROUP ONLY *****


Empire Health Assurance, Inc. PO Box 659960 San Antonio, TX 78265-9146 empireblue.com

<Subscriber first name> <Subscriber last name> May 20, 2019 <Subscriber address> <Subscriber city>, <state> <zip>

Notice of premium rate and health plan change <Product name>

Health Insurance Oversight System (HIOS) Plan ID number <2019 HIOS ID> Dear <Subscriber first name> <Subscriber last name>, We write to inform you of two important changes concerning your current policy: (1) New policies. Starting in 2020, Empire HealthChoice Assurance, the entity that administers

your current policy, will no longer offer comprehensive health insurance policies in New York’s individual market. You will need to choose a new policy in order to have coverage after December 31, 2019.

You don’t have to take any action now. We will send you a notice in the fall with information about the options available to you for health insurance coverage in 2020 and how to choose a new plan from Empire or from another insurer in your service area. Subject to state approval, new individual policies will be offered by our sister plan, <Empire BlueCross BlueShield> HealthPlus (“Empire HealthPlus”). Empire HealthPlus will offer benefit plans to individuals, including an individual policy comparable to the one you have today with a new provider network.

(2) New premium rates. Empire HealthPlus is filing a request with the New York State

Department of Financial Services (DFS) to approve new individual products and rates in 2020. DFS may approve, modify or disapprove the requested products and rates. Information about the new rates and how they compare to your current plan are listed below.

06093_NYMENMUB_NY_LTR_NOF 5/19 2

Proposed premium rates if you elect to remain with Empire in 2020: The chart below shows the requested percentage change to the premium rate for your present plan as compared to the new plans Empire HealthPlus will offer. Your current plan: <2019 PLAN NAME> (HealthChoice Assurance plan) Proposed New Plan Option and Rate Change: 2019 Plan Name (HealthChoice Assurance plan)

2020 Plan Name (HealthPlus plan)

Proposed Percentage Rate Change

<2019 PLAN NAME> <2020 PLAN NAME> <PERCENTAGE> If you enrolled through the NY State of Health, the state’s health plan marketplace, and you qualified for financial assistance, called an Advance Premium Tax Credit (APTC), your 2020 premium increase may be different from what is shown above. If you remain eligible, NY State of Health will calculate your eligibility for financial assistance for 2020 and include this information in your NY State of Health renewal notice. Please note that while we try to provide you with the most accurate information possible, the final approved rate may differ as a result of the DFS rate approval action. Why We Are Making this Request The requested changes in our health plans reflects our evaluation of current market trends and issues, including the rising cost of medical care, a changing pool of customers and our experience with provider networks. The rates also reflect coverage changes to some deductibles, copays, coinsurance, benefit limits, and/or annual out-of-pocket maximum amounts. 30-day Comment Period You can contact us or DFS to ask for more information or submit comments to DFS about the proposed rate change. The comments must be made within 30 days from the date of this notice. Comments or requests for more information on the proposed rate change may be submitted to DFS by visiting the DFS Website or via standard mail as follows:

DFS Website: www.dfs.ny.gov/healthinsurancepremiums

United States Postal Service:

NYS Department of Financial Services Health Bureau – Premium Rate Adjustments One Commerce Plaza Albany, NY 12257

http://www.dfs.ny.gov/healthinsurancepremiums

06093_NYMENMUB_NY_LTR_NOF 5/19 3

If you choose to submit comments to DFS, please include the following information: 1. The name of your insurer, which is Empire Health Choice Assurance, Inc. 2. The name of your Empire benefit plan 3. Indicate you have individual coverage 4. Your HIOS identification number, which is 2019 HIOS ID <no.> / 2020 HIOS ID <no.>

Written comments submitted to DFS will be posted on the DFS website without your personal information. Plain English Summary of Rate Change We have prepared a plain-English summary that provides a more detailed explanation of the reasons why a premium rate change is being requested. You can find this information at the following websites:

Empire website: www.empiteblue.com/ratefiling DFS website: www.dfs.ny.gov/healthinsurancepremiums

Notice of Approved Premium Rate After DFS approves the final premium rate, which may differ from the requested rate noted above, you will receive final information before you need to select a new 2020 benefit plan. You can contact <Empire BlueCross BlueShield> for additional information at: <Empire BlueCross BlueShield> PO Box 659960 San Antonio, TX 78265-9146 Telephone: please see the number on the back of your Empire Health plan ID card Website: www.empireblue.com/health-insurance/customer-care/email-us Getting help in other languages Need this information in another language? The last page explains how to get help. Sincerely,

Alan J. Murray President, New York Commercial Services provided by Empire HealthChoice Assurance, Inc. and/or HealthPlus HP, LLC., independent licensees of the Blue Cross and Blue Shield Association.

http://www.dfs.ny.gov/healthinsurancepremiums

NY_OFFHIX_ST_HP_GK_CHILD(1/20)

NY_OFFHIX_ST_HP_GK_CAT(1/20)

NY_ONHIX_ST_HP_GK_CAT(1/20)

The Memorandum provides support to the rate development and demonstrates that rates are established

in compliance with state laws and provisions of the Affordable Care Act. The rates proposed in this

submission reflect the insurer participation in the market and regulatory framework as of May 13, 2019. If

the regulatory framework or insurer participation in the market change after this date, proposed rates

may no longer be appropriate and should be reevaluated for revision and resubmission. This rate filing is

not intended to be used for other purposes.

Policy Form Number(s):

NY_ONHIX_ST_HP_GK(1/20)

NY_OFFHIX_ST_HP_GK(1/20)

NY_ONHIX_ST_HP_GK_CHILD(1/20)

Primary Contact Telephone Number:

Primary Contact Email Address:

2. Scope and Purpose of the Filing

This is a rate filing for the Individual market ACA-compliant plans offered by HealthPlus HP, LLC, also

referred to as HealthPlus. The policy forms associated with these plans are listed below. The proposed

rates in this filing will be effective for the 2020 plan year beginning January 1, 2020, and apply to plans On-

Exchange and Off-Exchange.

Market:

Effective Date:

16574

Individual

January 1, 2020

• Company Contact InformationPrimary Contact Name:

State: New York

HIOS Issuer ID: 41046

NAIC Company Code:

ACTUARIAL MEMORANDUM

1. General Information

• Company Identifying InformationCompany Legal Name: HealthPlus HP, LLC

Page 1

Inpatient Hospital: Includes non-capitated facility services for medical, surgical, maternity,

mental health and substance abuse, skilled nursing, and other services provided in an inpatient

facility setting and billed by the facility.

• Allowed and Incurred Claims Incurred During the Experience Period

The allowed claims are determined by subtracting non-covered benefits, provider discounts, and

coordination of benefits amounts from the billed amount.

Allowed and incurred claims are completed using the chain ladder method, an industry standard, by

using historic paid vs. incurred claims patterns. The method calculates historic completion

percentages, representing the percent of cumulative claims paid of the ultimate incurred amounts for

each lag month. Claim backlog files are reviewed on a monthly basis and are accounted for in the

historical completion factor estimates.

Allowed and incurred claims are $311,912,993 and $273,354,859, respectively. Note that the URRT

requires that the experience period claims be legal entity specific. Since there are no experience

period claims for HealthPlus, the URRT is showing no experience period claims.

5. Benefit Categories

The methodology used to determine benefit categories in Worksheet 1, Section II of the URRT is as

follows:

The experience period premium and claims used are for the non-grandfathered, single risk pool compliant

policies of the identified legal entity in the Individual market.

• Paid Through Date

The experience claims used reflects the incurred claims from January 1, 2018 through December 31,

2018 based on claims paid through February 28, 2019.

• Premiums (net of MLR Rebate) Experience Period

The earned premium prior to MLR rebate is $241,487,334. The earned premium reflects the pro-rata

share of premium based on policy coverage dates.

The preliminary MLR rebate estimate is $0, which is consistent with Empire HealthChoice Assurance,

Inc's December 31, 2018 general ledger estimate allocated to the non-grandfathered portion of

Individual business. This is an estimated amount and will not be final until 7/31/2019. Using this MLR

estimate, the net earned premium is $241,487,334 for the legal entity.

3. Executive Summary

In 2020, Empire HealthChoice Assurance's Individual products will be replaced with products offered by

HealthPlus. The HealthPlus network will provide greater symmetry with other Individual products offered

by HealthPlus, such as the Essential Plan and Child Health Plus. Factors that typically increase rates have

been slightly more than offset by the favorability of HealthPlus' revised reimbursement schedule. The net

rate increase is the result of the reinstatement of the ACA Health Insurer fee.

4. Experience and Current Period Premium, Claims, and Enrollment

Page 2

-

HealthPlus believes that additional morbidity improvement will be realized due to the

anticipated healthier risk cohort of new members. Exhibit E shows the projected impact of

morbidity changes.

• Changes in Demographics (Normalization)

The experience period claims are normalized to reflect anticipated changes in age/gender, area,

network, and benefit plan in the projection period. Exhibit D provides detail of each normalization

factor below:

Age/Gender: The assumed claims cost is applied by age and gender to the experience period

membership distribution and the projection period membership distribution.

Area/Network: Adjustments made to reflect the differences in the area claims factors are

developed based on an analysis of allowed claims by network and area in the experience and

projection periods.

6. Projection Factors

The experience period claims in Worksheet 1, Section I of the URRT are projected to the projection period

using the factors described below. Exhibit C provides a summary of the factors.

• Trend Factors (cost/utilization)

The trend is developed by normalizing historical benefit expense for changes in the underlying

population and known cost drivers, which are then projected forward to develop the pricing

trend. Examples of such changes include contracting, cost of care initiatives, workdays, average

wholesale price, and expected introduction of generic drugs. For projection, the experience

period claims are trended 24.0 months from the member-weighted midpoint of the experience

period, which is June 30, 2018, to the member-weighted midpoint of the projection period,

which is July 1, 2020. Details are in Exhibit E.

• Morbidity Adjustment

Company Change

Outpatient Hospital: Includes non-capitated facility services for surgery, emergency room, lab,

radiology, therapy, observation and other services provided in an outpatient facility setting and

billed by the facility.

Professional: Includes non-capitated primary care, specialist, therapy, the professional

component of laboratory and radiology, and other professional services, other than hospital-

based professionals whose payments are included in facility fees.

Other Medical: Includes non-capitated ambulance, home health care, DME, prosthetics, supplies,

vision exams, and dental services.

Capitation: Includes all services provided under one or more capitated arrangements.

Prescription Drug: Includes drugs dispensed by a pharmacy and rebates received from drug

manufacturers.

Page 3

-

-

-

-

-

-

Benefits in excess of the essential health benefits in the projection period are included.

Covered Lives Assessment

This indirect New York tax is a charge on all fully and self-insured "covered lives." The

purpose of the Covered Lives Assessment is to raise funds for a variety of state programs

and for the state budget. The Assessment is included in claims costs for purposes of

calculating MLR.

Elective Abortions

7. Credibility of Experience

With 24,883 members, the credibility level assigned to the experience period claims is 100%.

Therefore, a manual rate was not used in the rate development.

Expansion of medically necessary coverage for fertility preservation

Fertility preservation age limit removal

Change to prostate diagnostic testing cost sharing

Grace Period: The claims experience has been adjusted to account for incidences of enrollees not

paying premiums due during the first month of the 90-day grace period when the QHP is liable

for paying claims.

Rx Rebates: The projected claims cost is adjusted to reflect anticipated Rx rebates. These

projections take into account the most up-to-date information regarding anticipated rebate

contracts, drug prices, anticipated price inflation, and upcoming patent expirations.

Projected costs of pediatric dental and vision benefits are included.

• Plan Design Changes

Rx Adjustments: Adjustments are made to reflect differences in the Rx formulary, Rx networks

and discounts, and mail order programs between the experience period and the projection

period. Exhibit E shows the adjustment factor.

• Other Adjustments

Other adjustments to the experience claims data include the following items. Exhibit C, Exhibit E and

Exhibit F show the factors for each adjustment.

Mandates:

Change to Behavioral Health cost sharing

Benefit Plan: The experience period claims are normalized to reflect the average benefit level in

the projection period using benefit relativities. The benefit relativities include the value of cost

shares and anticipated changes in utilization due to the difference in average cost share

requirements.

Page 4

Provider Network Adjustments: This is a multiplicative factor that adjusts for differences in

projected claims cost due to different network discounts.

Adjustments for Benefits in Addition to the Essential Health Benefits: This factor adjusts for

additional non-EHB benefits shown in Exhibit F.

Catastrophic Plan Adjustment: This adjustment reflects the projected costs of the population

eligible for catastrophic plans. The catastrophic adjustment factor is applied to catastrophic

plans only; all other plans have an adjustment factor of 1.0.

9. Development of the Market-wide Adjusted Index Rate

• Projected Risk Adjustments PMPM

Experience period risk adjustment estimate is based on an independent consultant's market study.

The 2018 CMS Interim Risk Adjustment results were also reviewed and confirmed Empire's

estimation. This adjustment is shown in line item 2 of Exhibit C: Index Rate Development. Should the

final risk transfer results differ from this initial estimation, the rates would need to be adjusted

accordingly. Per the DFS's guidance, HealthPlus assumes the DFS will not make a uniform adjustment

to the anticipated final 2020 aggregate federal risk adjustment pool transfers. The projected risk

adjustment fee is shown in Exhibit G.

10. Plan Adjusted Index Rate

The Plan Adjusted Index Rate is calculated as the Market-wide Adjusted Index Rate adjusted for all

allowable plan level modifiers defined in the market rating rules. Exhibit J shows the development. The

plan level modifiers are described below:

AV and Cost Sharing Adjustments: This is a multiplicative factor that adjusts for the projected

paid/allowed ratio of each plan, based on the AV metal value with an adjustment for utilization

differences due to differences in cost sharing.

8. Establishing the Index Rate

• Experience Period Index Rate

The experience period Index Rate is equal to the allowed claims PMPM for the essential health

benefits of HealthPlus's non-grandfathered business in the Individual market. The experience period

Index Rate is $0. Note that the URRT requires that the experience period claims be legal entity

specific. Since there are no experience period claims for HealthPlus, the URRT is showing no

experience period claims.

• Projection Period Index Rate

The projection period Index Rate is equal to projected allowed claims PMPM for the essential health

benefits of HealthPlus's non-grandfathered business in the Individual market. It reflects the

anticipated claim level of the projection period including impact from trend, benefit, network, and

demographics as described in Section 6 of this memo.

The projected index rate is reported in Worksheet 1, Section II, cell F42 of the URRT and is also shown

in Exhibit C. Note there are minor variances between the Projection Period Index Rate in the URRT

and Actuarial Memorandum due to rounding methodology in the URRT. No benefits in excess of the

essential health benefits have been included in this amount.

Page 5

Membership projections are reported in Worksheet 2, Section IV of the URRT. They are based on

historical and current enrollment, expected new sales and lapses.

Exhibit I shows the projected Federal MLR for the products in this filing. The calculation is an estimate

and is not meant to be a true measure for Federal or State MLR rebate purposes. The products in this

filing represent only a subset of HealthPlus's Individual business. The MLR for HealthPlus's entire book

of Individual business will be compared to the minimum Federal benchmark for purposes of

determining regulation-related premium refunds. Also note that the projected Federal MLR

presented here does not capture all adjustments, including but not limited to: three-year averaging,

credibility, dual option, and deductible. HealthPlus's projected MLR is expected to meet or exceed the

minimum MLR standards at the market level after including all adjustments.

14. Area Factors

The area factors have been updated for 2020 as shown in Exhibit N. The area factors have been adjusted

on a revenue-neutral basis.

15. Actuarial Value Metal Values

The Actuarial Value (AV) Metal Values reported in Worksheet 2, Section I of the URRT are based on the AV

Calculator. To the extent a component of the benefit design was not accommodated by an available input

within the AV Calculator, the benefit characteristic was adjusted to be actuarially equivalent to an

available input within the AV Calculator for purposes of utilizing the AV Calculator as the basis for the AV

Metal Values. When applicable, benefits for plans that are not compatible with the parameters of the AV

Calculator have been separately identified and documented in the Unique Plan Design Supporting

Documentation and Justification that supports the Plan & Benefits Template.

16. Membership Projections

• Conversion Factor

The Conversion Factor development is summarized in Exhibit M.

12. Consumer Adjusted Premium Rate Development

The Consumer Adjusted Premium Rate is calculated by calibrating the Plan Adjusted Index Rate by the

Contract Type and Conversion factors described above, and applying consumer specific geographic rating

factors. Exhibit O has the sample rate calculations.

13. Projected Loss Ratio

• Projected Federal MLR

Adjustments for Distribution and Administrative Cost: This is an additive adjustment that includes

all the selling expense, administration and retention Items shown in Exhibit H.

11. Calibration

The Plan Adjusted Index Rate is calibrated by the Contract Type and Geographic factors so that the

schedule of premium rates for each plan can be further developed. Exhibit K shows the calibration factors.

Page 6

(2) The Index Rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and

156.80(d)(2) were used to generate plan level rates.

(3) The geographic rating factors reflect only differences in the costs of delivery (which can include

unit cost and provider practice pattern differences) and do not include differences for population

morbidity by geographic area.

(4) The most recent AV Calculator was used to determine the AV Metal Values shown in Worksheet 2

of the Part I Unified Rate Review Template for all plans.

The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop

the rates. Rather it represents information required by Federal regulation to be provided in support of the

review of rate changes, for certification of Qualified Health Plans for Federally-Facilitated Exchanges, and

for certification that the Index Rate is developed in accordance with Federal regulation, used consistently,

and only adjusted by the allowable modifiers. However, this Actuarial Memorandum does accurately

describe the process used by the issuer to develop the rates.

I, , am an actuary for HealthPlus. I am a member of the American Academy of

Actuaries and a Fellow of the Society of Actuaries. I meet the Qualification Standards of the American

Academy of Actuaries to render the actuarial opinion contained herein. I hereby certify that the following

statements are true to the best of my knowledge with regards to this filing:

(1) The projected Index Rate is:

In compliance with all applicable state and Federal statutes and regulations (45 CFR 156.80 and

147.102)

Developed in compliance with the applicable Actuarial Standards of Practice

Reasonable in relation to the benefits provided and the population anticipated to be covered

Not excessive nor deficient

17. Plan Type

The plan type for each plan reported in Worksheet 2, Section I of the URRT is consistent with the option

chosen from the drop-down box.

18. Reliance

In support of this rate development, various data and analyses were provided by other members of

Anthem’s actuarial staff, including data and analysis related to cost of care, valuation, and pricing. I have

reviewed the data and analyses for reasonableness and consistency. I have also relied on

to provide the actuarial certification for the Unique Plan Design Supporting Documentation

and Justification for plans included in this filing.

19. Actuarial Certification

Page 7


Company Name: Empire Healthchoice Assurance HealthPlus HP, LLCNAIC Code: 55093 16574SERFF Tracking #: AWLP-131950100Market Segment: Individual

A. Insurer Information: HMO - 44 For Profit 55093Company submitting the rate filing request Company Type Org. Type Company NAIC Code

B. Contact Person: Rate filing contact person name, title Contact phone number Contact Email address

C. Actuarial Contact (If different from above): Actuary name, title Actuary phone number Actuary Email address

D. New Rate Information: AWLP-131922540New rate applicability period New rate effective date SERFF Tracking Number

E.

F. Provide responses for the following questions:1.

2.

3.

4.

5.

6

Notes:(1)

(2)

As mentioned in the checklist, this combined non-grandfathered product rate adjustment and form/rate filing can only include minor contract revisions, such as due to changes in the model language, changes to the catastrophic plan due to change in out of pocket maximum, changes to the standard plan designs. Substantial changes need to be submitted as a separate rate and form filing (e.g., a new plan design not replacing an existing plan design, contract language changes not just due to changes in the model language).For purposes of complying with §3231(e)(1)(A) and §4308(c)(2) of the New York Insurance Law, rate applications will be considered to have been submitted after all of the relevant rate applications have been posted on theDepartment's website. Once the rate applications have been posted, the Department will send a blast email instructing insurers to send their initial rate notices to policy/certificate holders. Notices should not be sent priorto having received the blast email from the Department. Note that the 60 (or 80) day review period will begin on the day in which DFS designates as the filing due date and the 30 day consumer comment period will beginon the date DFS sends the blast email to insurers.

Have all the required exhibits been submitted with this rate filing? If any exhibit is not applicable, has an explanation been provided why such exhibit is not applicable?

YesDid the company submit a "Prior Approval Pre-filing" containing a draft of the initial notice and a draft of the narrative summary and numerical summary associated with this rate filing? Indicate Yes or No, and if Yes, please provide the SERFF number of the pre-filing.

Yes, SERFF Tracking Number AWLP-13193845745 CFR 154.215 requires companies to submit rate filings via SERFF and HIOS simultaneously. Did the company submit this rate filing in HIOS? If yes, please provide the HIOS submission tracking number.

The HIOS submission is required by 5/31

Confirm that initial notices have not been sent to any impacted policyholders and will not be sent until the Company has received confirmation that all relevant 2020 rate applications have been posted on the Department's website. See note (2).

Yes

1/1/2020 - 12/31/2020 1/1/2020

Market segment included in filing (e.g., Small Group (including Healthy NY Small Group), Individual - only one market segment per rate adjustment filing): Individual

ResponseDoes this filing include any revision to contract language that is not yet approved? See note (1). If yes, provide a brief description of the contract language changes included in this filing.

No, they are contained in the companion filing.Are there any rate filings submitted and not yet approved that if approved would affect the rate tables included in this rate filing? If yes, mention these filings on Exhibit 16.

No

EXHIBIT 11: GENERAL INFORMATION

HealthPlus HP, LLC

Company mailing address14 Wall Street, New York, NY 10005

DFS

Cross-Out

DFS

Cross-Out

Exhibit 13a Updated by DFS 3/14/2018 1

EXHIBIT 13a: NUMERICAL SUMMARY AND RATE INDICATION CALCULATION

NUMERICAL SUMMARY

Empire Healthchoice Assurance HealthPlus HP, LLC55093 16574

SERFF Tracking #: AWLP-131950100Market Segment: Individual

1 Please complete the Numerical Summary below as well as the Narrative Summary (a separate attachment) for each market segment for which a rate filing is being submitted.2 The Narrative Summary must be in plain English and should clearly and simply explain the reasons for the requested rate adjustment (This should be included in the provided blank template "2020 Exhibit 13b - Narrative Summary.docx")3 The purpose of the Narrative Summary is to provide a written explanation to the company's policyholders to help them understand the reasons why a rate increase is needed. 4 The purpose of the Numerical Summary is to provide a clear and simple overview of the requested rate adjustment. 5 These Summaries (with the exception of the Rate Indication Calculation Section) will be public documents and will be posted on DFS’s website and furnished by DFS to the public upon request. 6 The company should submit these Summaries to DFS ten (10) days before submitting a rate adjustment filing.7 A draft of these Summaries and of the Initial Notice must be included in a "Prior Approval Pre-filing" submitted to DFS via SERFF.8 Once reviewed by DFS, these Summaries must be posted to a location on its website that is publicly available and accessible without the need for a user ID/password. 9 Links should be provided on key pages of the company's website so that the information may be easily located.

10 Any change(s) made to the Narrative Summary/Numerical Summary subsequent to the posting must be submitted to DFS with the specific change(s) identified.11 Rate Change Adjustment calculations between Year 2019 and 2020 should be based on the DFS Membership Survey data as of 3/31/2019.12 This exhibit must be submitted as an Excel file and as a PDF file.

A. Average 2019 and 2020 Premium Rates:1 Weighted Average Monthly Base Premium Rates are as calculated in Row 32 of the appropriate columns in Exhibit 13c (Columns L-P for 2019 and Columns U-Y for 2020)2 Premium Rates for 2020 should be Consistent with the Premium Rates reflected in Exhibit 23.

Average Individual Rate Average Individual Rate Average Individual Rate Average Individual Rate Average Individual RatePlatinum Gold Silver Bronze Catastrophic

2019 Weighted Average Base Premium Rates 1,254.60$ 1,004.86$ 822.16$ 613.24$ 282.65$ 2020 Weighted Average Base Premium Rates 1,279.42$ 1,037.97$ 842.02$ 623.58$ 279.06$

B. Weighted Average Annual Percentage Requested Adjustments:

2019 Weighted Average PMPM Rate 2020 Weighted Average PMPM Rate2019 to 2020 All - Metals All - Metals

Requested Rate Adjustment 2.36111% 760.18$ 778.13$ From Ce ls Q-74 and Z-74 of Exhibit 13c

C. Weighted Average Annual Percentage Adjustments for each of the Past Two Years [If Applicable]*:2017 to 2018 2018 to 2019

Average Rate Adjustment Requested N/A N/AAverage Rate Adjustment Approved N/A N/A

D. Average Medical Loss Ratios [MLR] for All Policies Impacted [Ratios of Incurred Claims to Earned Premiums] [If Applicable]*:2016 2017 2018

MLR N/A N/A N/A

E. Claim Trend Rates and Average Ratios to Earned Premiums [Per Exhibit 19 for 2018-2020 and Comparable Exhibits for 2018] [If Applicable]*:2018 2019 2020

Annual Claim Trend Rates N/A 11.5% 7.88%Expense Ratios N/A 10.1% 12.7%Pre Tax Profit Ratios N/A 1.5% 1.0%* If no products were offered in a particular year, indicate "N/A" in the applicable box.

Company NAIC Code:

DFS

Cross-Out

DFS

Cross-Out

NY_OFFHIX_ST_HP_GK_CHILD(1/20)

NY_OFFHIX_ST_HP_GK_CAT(1/20)

NY_ONHIX_ST_HP_GK_CAT(1/20)

The Memorandum provides support to the rate development and demonstrates that rates are established

in compliance with state laws and provisions of the Affordable Care Act. The rates proposed in this

submission reflect the insurer participation in the market and regulatory framework as of May 13, 2019. If

the regulatory framework or insurer participation in the market change after this date, proposed rates

may no longer be appropriate and should be reevaluated for revision and resubmission. This rate filing is

not intended to be used for other purposes.

Policy Form Number(s):

NY_ONHIX_ST_HP_GK(1/20)

NY_OFFHIX_ST_HP_GK(1/20)

NY_ONHIX_ST_HP_GK_CHILD(1/20)

Primary Contact Telephone Number:

Primary Contact Email Address:

2. Scope and Purpose of the Filing

This is a rate filing for the Individual market ACA-compliant plans offered by HealthPlus HP, LLC, also

referred to as HealthPlus. The policy forms associated with these plans are listed below. The proposed

rates in this filing will be effective for the 2020 plan year beginning January 1, 2020, and apply to plans On-

Exchange and Off-Exchange.

• Company Contact InformationPrimary Contact Name:

State: New York

HIOS Issuer ID: 41046

NAIC Company Code: 16574

ACTUARIAL MEMORANDUM

1. General Information

• Company Identifying InformationCompany Legal Name: HealthPlus HP, LLC

Market: Individual

Effective Date: January 1, 2020

Page 1

Inpatient Hospital: Includes non-capitated facility services for medical, surgical, maternity,

mental health and substance abuse, skilled nursing, and other services provided in an inpatient

facility setting and billed by the facility.

• Allowed and Incurred Claims Incurred During the Experience Period

The allowed claims are determined by subtracting non-covered benefits, provider discounts, and

coordination of benefits amounts from the billed amount.

Allowed and incurred claims are completed using the chain ladder method, an industry standard, by

using historic paid vs. incurred claims patterns. The method calculates historic completion

percentages, representing the percent of cumulative claims paid of the ultimate incurred amounts for

each lag month. Claim backlog files are reviewed on a monthly basis and are accounted for in the

historical completion factor estimates.

Allowed and incurred claims are $311,912,993 and $273,354,859, respectively. Note that the URRT

requires that the experience period claims be legal entity specific. Since there are no experience

period claims for HealthPlus, the URRT is showing no experience period claims.

5. Benefit Categories

The methodology used to determine benefit categories in Worksheet 1, Section II of the URRT is as

follows:

The experience period premium and claims used are for the non-grandfathered, single risk pool compliant

policies of the identified legal entity in the Individual market.

• Paid Through Date

The experience claims used reflects the incurred claims from January 1, 2018 through December 31,

2018 based on claims paid through February 28, 2019.

• Premiums (net of MLR Rebate) Experience Period

The earned premium prior to MLR rebate is $241,487,334. The earned premium reflects the pro-rata

share of premium based on policy coverage dates.

The preliminary MLR rebate estimate is $0, which is consistent with Empire HealthChoice Assurance,

Inc's December 31, 2018 general ledger estimate allocated to the non-grandfathered portion of

Individual business. This is an estimated amount and will not be final until 7/31/2019. Using this MLR

estimate, the net earned premium is $241,487,334 for the legal entity.

3. Executive Summary

In 2020, Empire HealthChoice Assurance's Individual products will be replaced with products offered by

HealthPlus. The HealthPlus network will provide greater symmetry with other Individual products offered

by HealthPlus, such as the Essential Plan and Child Health Plus. Factors that typically increase rates have

been slightly more than offset by the favorability of HealthPlus' revised reimbursement schedule. The net

rate increase is the result of the reinstatement of the ACA Health Insurer fee.

4. Experience and Current Period Premium, Claims, and Enrollment

Page 2

-

HealthPlus believes that additional morbidity improvement will be realized due to the

anticipated healthier risk cohort of new members. Exhibit E shows the projected impact of

morbidity changes.

• Changes in Demographics (Normalization)

The experience period claims are normalized to reflect anticipated changes in age/gender, area,

network, and benefit plan in the projection period. Exhibit D provides detail of each normalization

factor below:

Age/Gender: The assumed claims cost is applied by age and gender to the experience period

membership distribution and the projection period membership distribution.

Area/Network: Adjustments made to reflect the differences in the area claims factors are

developed based on an analysis of allowed claims by network and area in the experience and

projection periods.

6. Projection Factors

The experience period claims in Worksheet 1, Section I of the URRT are projected to the projection period

using the factors described below. Exhibit C provides a summary of the factors.

• Trend Factors (cost/utilization)

The trend is developed by normalizing historical benefit expense for changes in the underlying

population and known cost drivers, which are then projected forward to develop the pricing

trend. Examples of such changes include contracting, cost of care initiatives, workdays, average

wholesale price, and expected introduction of generic drugs. For projection, the experience

period claims are trended 24.0 months from the member-weighted midpoint of the experience

period, which is June 30, 2018, to the member-weighted midpoint of the projection period,

which is July 1, 2020. Details are in Exhibit E.

• Morbidity Adjustment

Company Change

Outpatient Hospital: Includes non-capitated facility services for surgery, emergency room, lab,

radiology, therapy, observation and other services provided in an outpatient facility setting and

billed by the facility.

Professional: Includes non-capitated primary care, specialist, therapy, the professional

component of laboratory and radiology, and other professional services, other than hospital-

based professionals whose payments are included in facility fees.

Other Medical: Includes non-capitated ambulance, home health care, DME, prosthetics, supplies,

vision exams, and dental services.

Capitation: Includes all services provided under one or more capitated arrangements.

Prescription Drug: Includes drugs dispensed by a pharmacy and rebates received from drug

manufacturers.

Page 3

-

-

-

-

-

-

Benefits in excess of the essential health benefits in the projection period are included.

Covered Lives Assessment

Elective Abortions

• Exhibit 18 Documentation

The following bullet points document lines 24-26 and 44-45 in Exhibit 18:

Line 44 represents pediatric dental and pediatric vision. These fixed cost assumptions vary by

metal level.

Line 24 represents the change in the age/gender factor. Claim costs are applied by age and

gender to the experience period membership distribution and the projection period membership

distribution.

Line 25 represents the expected morbidity. HealthPlus believes that additional morbidity

improvement will be realized due to the anticipated healthier risk cohort of new members.

Line 26 represents the grace period factor. The claims experience is adjusted to account for

incidences of enrollees not paying premiums due during the first month of the 90-day grace

period when the QHP is liable for paying claims.

Expansion of medically necessary coverage for fertility preservation

Fertility preservation age limit removal

Change to prostate diagnostic testing cost sharing

Grace Period: The claims experience has been adjusted to account for incidences of enrollees not

paying premiums due during the first month of the 90-day grace period when the QHP is liable

for paying claims.

Rx Rebates: The projected claims cost is adjusted to reflect anticipated Rx rebates. These

projections take into account the most up-to-date information regarding anticipated rebate

contracts, drug prices, anticipated price inflation, and upcoming patent expirations.

Projected costs of pediatric dental and vision benefits are included.

• Plan Design Changes

Rx Adjustments: Adjustments are made to reflect differences in the Rx formulary, Rx networks

and discounts, and mail order programs between the experience period and the projection

period. Exhibit E shows the adjustment factor.

• Other Adjustments

Other adjustments to the experience claims data include the following items. Exhibit C, Exhibit E and

Exhibit F show the factors for each adjustment.

Mandates:

Change to Behavioral Health cost sharing

Benefit Plan: The experience period claims are normalized to reflect the average benefit level in

the projection period using benefit relativities. The benefit relativities include the value of cost

shares and anticipated changes in utilization due to the difference in average cost share

requirements.

Page 4

10. Plan Adjusted Index Rate

The Plan Adjusted Index Rate is calculated as the Market-wide Adjusted Index Rate adjusted for all

allowable plan level modifiers defined in the market rating rules. Exhibit J shows the development. The

plan level modifiers are described below:

• Projection Period Index Rate

The projection period Index Rate is equal to projected allowed claims PMPM for the essential health

benefits of HealthPlus's non-grandfathered business in the Individual market. It reflects the

anticipated claim level of the projection period including impact from trend, benefit, network, and

demographics as described in Section 6 of this memo.

The projected index rate is reported in Worksheet 1, Section II, cell F42 of the URRT and is also shown

in Exhibit C. Note there are minor variances between the Projection Period Index Rate in the URRT

and Actuarial Memorandum due to rounding methodology in the URRT. No benefits in excess of the

essential health benefits have been included in this amount.

9. Development of the Market-wide Adjusted Index Rate

• Projected Risk Adjustments PMPM

Experience period risk adjustment estimate is based on an independent consultant's market study.

The 2018 CMS Interim Risk Adjustment results were also reviewed and confirmed Empire's

estimation. This adjustment is shown in line item 2 of Exhibit C: Index Rate Development. Should the

final risk transfer results differ from this initial estimation, the rates would need to be adjusted

accordingly. Per the DFS's guidance, HealthPlus assumes the DFS will not make a uniform adjustment

to the anticipated final 2020 aggregate federal risk adjustment pool transfers. The projected risk

adjustment fee is shown in Exhibit G.

Line 45 represents Rx adjustments, covered lives assessment (CLA), and rounding. The Rx

adjustment is the average adjustment for Rx coverage between the experience period and

projection period. The covered lives assessment is a fixed amount applied to all plans. A final

small rounding adjustments varies by plan and is used to get back to final charged premium.

7. Credibility of Experience

With 24,883 members, the credibility level assigned to the experience period claims is 100%.

Therefore, a manual rate was not used in the rate development.

8. Establishing the Index Rate

• Experience Period Index Rate

The experience period Index Rate is equal to the allowed claims PMPM for the essential health

benefits of HealthPlus's non-grandfathered business in the Individual market. The experience period

Index Rate is $0. Note that the URRT requires that the experience period claims be legal entity

specific. Since there are no experience period claims for HealthPlus, the URRT is showing no

experience period claims.

Page 5

The Consumer Adjusted Premium Rate is calculated by calibrating the Plan Adjusted Index Rate by the

Contract Type and Conversion factors described above, and applying consumer specific geographic rating

factors. Exhibit O has the sample rate calculations.

13. Projected Loss Ratio

• Projected Federal MLR

Exhibit I shows the projected Federal MLR for the products in this filing. The calculation is an estimate

and is not meant to be a true measure for Federal or State MLR rebate purposes. The products in this

filing represent only a subset of HealthPlus's Individual business. The MLR for HealthPlus's entire book

of Individual business will be compared to the minimum Federal benchmark for purposes of

determining regulation-related premium refunds. Also note that the projected Federal MLR

presented here does not capture all adjustments, including but not limited to: three-year averaging,

credibility, dual option, and deductible. HealthPlus's projected MLR is expected to meet or exceed the

minimum MLR standards at the market level after including all adjustments.

Adjustments for Distribution and Administrative Cost: This is an additive adjustment that includes

all the selling expense, administration and retention Items shown in Exhibit H.

11. Calibration

The Plan Adjusted Index Rate is calibrated by the Contract Type and Geographic factors so that the

schedule of premium rates for each plan can be further developed. Exhibit K shows the calibration factors.

• Conversion Factor

The Conversion Factor development is summarized in Exhibit M.

12. Consumer Adjusted Premium Rate Development

AV and Cost Sharing Adjustments: This is a multiplicative factor that adjusts for the projected

paid/allowed ratio of each plan, based on the AV metal value with an adjustment for utilization

differences due to differences in cost sharing.

Provider Network Adjustments: This is a multiplicative factor that adjusts for differences in

projected claims cost due to different network discounts.

Adjustments for Benefits in Addition to the Essential Health Benefits: This factor adjusts for

additional non-EHB benefits shown in Exhibit F.

Catastrophic Plan Adjustment: This adjustment reflects the projected costs of the population

eligible for catastrophic plans. The catastrophic adjustment factor is applied to catastrophic

plans only; all other plans have an adjustment factor of 1.0.

Page 6

17. Plan Type

The plan type for each plan reported in Worksheet 2, Section I of the URRT is consistent with the option

chosen from the drop-down box.

18. Reliance

In support of this rate development, various data and analyses were provided by other members of

Anthem’s actuarial staff, including data and analysis related to cost of care, valuation, and pricing. I have

reviewed the data and analyses for reasonableness and consistency. I have also relied on

to provide the actuarial certification for the Unique Plan Design Supporting Documentation

and Justification for plans included in this filing.

14. Area Factors

The area factors have been updated for 2020 as shown in Exhibit N. The area factors have been adjusted

on a revenue-neutral basis.

15. Actuarial Value Metal Values

The Actuarial Value (AV) Metal Values reported in Worksheet 2, Section I of the URRT are based on the AV

Calculator. To the extent a component of the benefit design was not accommodated by an available input

within the AV Calculator, the benefit characteristic was adjusted to be actuarially equivalent to an

available input within the AV Calculator for purposes of utilizing the AV Calculator as the basis for the AV

Metal Values. When applicable, benefits for plans that are not compatible with the parameters of the AV

Calculator have been separately identified and documented in the Unique Plan Design Supporting

Documentation and Justification that supports the Plan & Benefits Template.

16. Membership Projections

Membership projections are reported in Worksheet 2, Section IV of the URRT. They are based on

historical and current enrollment, expected new sales and lapses.

• Pricing MLR Formula

Note that in support of the SHIP initiative, HealthPlus will be voluntarily making Advanced Primary

Care (APC) payments to qualifying primary care providers in 2020. These payments are designed to

help primary care practices build infrastructure and coordinate care in furtherance of the SHIP goals

of raising the quality of care and controlling costs in the future. Based on historical payments to such

initiatives, HealthPlus is expected to make APC payments equal to $1.79 PMPM in 2020. The DFS has

announced that these payments could be included along with claims in the pricing MLR formula for

2020 premiums. Therefore, although these payments are currently classified as expenses in our

exhibits, they should be reclassified as claims when calculating the pricing MLR formula for 2020

premiums.

Page 7

May 13, 2019

Date

(4) The benefits are reasonable in relation to the premiums charged; and

(5) The preimums are not unreasonable, excessive, inadequate, or unfairly discriminatory.

The rates proposed in this submission reflect the regulatory framework and insurer participation in the

market as of May 13, 2019. If the regulatory framework or insurer participation in the market change

after this date, proposed rates may no longer be appropriate and should be reevaluated for revision and

resubmission. Issuer market entry and exit can have a significant impact on rates through the risk adjuster

mechanisms in the ACA and create a need for reconsideration and revision of proposed premium rates.

ASOP No. 25, Credibility Procedures

ASOP No. 41, Actuarial Communications

ASOP No. 42, Determining Health and Disability Liabilities other than Liabilities for Incurred

Claims

ASOP No. 45, The Use of Health Status Based Risk Adjustment Methodologies

ASOP No. 50, Determining Minimum Value and Actuarial Value under the Affordable Care

Act

(3) The expected loss ratio incorporated into the rate tables meets the minimum requirement of the

State of New York;

(1) The filing is in compliance with all applicable laws and regulations of the State of New York;

(2) The submission is in compliance with the appropriate Actuarial Standards of Practice (ASOPs)

including:

ASOP No. 5, Incurred Health and Disability Claims

ASOP No. 8, Regulatory Filings for Health Benefits, Accident and Health Insurance, and

Entities Providing Health Benefits

ASOP No. 12, Risk Classification

ASOP No. 23, Data Quality

19. Actuarial Certification

I, , am an actuary for HealthPlus. I am a member of the American Academy of

Actuaries and a Fellow of the Society of Actuaries. I meet the Qualification Standards of the American

Academy of Actuaries to render the actuarial opinion contained herein. I hereby certify that the following

statements are true to the best of my knowledge with regards to this filing:

Page 8

12345678910111213141516171819202122

232425262728293031323334353637383940414243444546474849

50515253545556575859606162636465666768697071727374

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AEIf Unified Rate Review v5.0 To add a product to Worksheet 2 ‐ Plan Product Info, select the Add Product button or Ctrl + Shift + P.

To add a plan to Worksheet 2 ‐ Plan Product Info, select the Add Plan button or Ctrl + Shift + L.Company Legal Name: HealthPlus HP, LLC State: NY To validate, select the Validate button or Ctrl + Shift + I.HIOS Issuer ID: 41046 Market: Individual To finalize, select the Finalize button or Ctrl + Shift + F.

Effective Date of Rate Change(s): 1/1/2020

Section I: Experience Period Data

Experience Period: 1/1/2018 to 12/31/2018

Total PMPM

$0.00 #DIV/0!

$0.00 #DIV/0!

$0.00 #DIV/0!

$0.00 #DIV/0!

$0.00 #DIV/0!

0

Section II: Projections

Cost Utilization Cost Utilization

Inpatient Hospital $0.00 0.000 0.000 0.000 0.000 $0.00

Outpatient Hospital $0.00 0.000 0.000 0.000 0.000 $0.00

Professional $0.00 0.000 0.000 0.000 0.000 $0.00

Other Medical $0.00 0.000 0.000 0.000 0.000 $0.00

Capitation $0.00 0.000 0.000 0.000 0.000 $0.00

Prescription Drug $0.00 0.000 0.000 0.000 0.000 $0.00

Total $0.00 $0.00

0.000

0.000

0.000

0.000

1/1/2020 $0.00

$799.54

0.00%

Projected Period Totals

1/1/2020 $799.54 $205,321,872.00

$0.00 $0.00

‐$0.21 ‐$53,928.00

0.00% $0.00

$799.75 $205,375,800.00

256,800

Market Level Calculations (Same for all Plans)

Trended EHB Allowed Claims

PMPM

Year 1 Trend Year 2 Trend

Allowed Claims

Reinsurance

Incurred Claims in Experience Period

Risk Adjustment

Experience Period Premium

Experience Period Member Months

Benefit Category

Experience Period Index

Rate PMPM

Other

Adjusted Trended EHB Allowed Claims PMPM for

Morbidity Adjustment

Information Not Releasable to the Public Unless Authorized by Law: This information has not been publically disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the

full extent of the law.

Projected Member Months

Projected Index Rate for

Reinsurance

Risk Adjustment Payment/Charge

Exchange User Fees

Market Adjusted Index Rate

Applied Credibility %

Manual EHB Allowed Claims PMPM

Demographic Shift

Plan Design Changes

1 of 5

If macros are disabled, press anProduct‐Plan Data Collection To add a product to Worksheet 2 ‐ Plan Product Info, select the Add Product but

To add a plan to Worksheet 2 ‐ Plan Product Info, select the Add Plan button or C

Company Legal Name: HealthPlus HP, LLC State: NY To validate, select the Validate button or Ctrl + Shift + I.

HIOS Issuer ID: 41046 Market: Individual To finalize, select the Finalize button or Ctrl + Shift + F.Effective Date of Rate Change(s): 1/1/2020

Field # Section I: General Product and Plan Information

1.1 Product Name

1.2 Product ID

1.3 Plan Name

HealthPlus

Gatekeeper X,

Catastrophic, ST,

INN, Pediatric

Dental

HealthPlus

Gatekeeper X,

Catastrophic, ST,

INN, Pediatric

Dental

HealthPlus

Gatekeeper X, for

HSA, Bronze, ST,

INN, Pediatric

Dental, Dep 25

HealthPlus

Gatekeeper X, for

HSA, Bronze, ST,

INN, Pediatric

Dental, Dep 25

HealthPlus

Gatekeeper X, for

HSA, Bronze, ST,

INN, Pediatric

Dental, Dep 29

HealthPlus

Gatekeeper X, for

HSA, Bronze, ST,

INN, Pediatric

Dental, Dep 29

HealthPlus

Gatekeeper X, for

HSA, Bronze, ST,

INN, Pediatric

Dental, Child Only

HealthPlus

Gatekeeper X, for

HSA, Bronze, ST,

INN, Pediatric

Dental, Child Only

HealthPlus

Gatekeeper X,

Silver, ST, INN,

Pediatric Dental,

Dep 25

HealthPlus

Gatekeeper X,

Silver, ST, INN,

Pediatric Dental,

Dep 29

HealthPlus

Gatekeeper X,

Silver, ST, INN,

Pediatric Dental,

Dep 29

HealthPlus

Gatekeeper X,

Silver Child Only,

ST, INN, Pediatric

Dental

HealthPlus

Gatekeeper X,

Silver Child Only,

ST, INN, Pediatric

Dental

HealthPlus

Gatekeeper X,

Silver, ST, INN,

Pediatric Dental,

Dep 25

HealthPlus

Gatekeeper X,

Gold Child Only,

ST, INN, Pediatric

Dental

1.4 Plan ID (Standard Component ID) 41046NY0010010 41046NY0010009 41046NY0010002 41046NY0010001 41046NY0010012 41046NY0010011 41046NY0010020 41046NY0010019 41046NY0010003 41046NY0010014 41046NY0010013 41046NY0010022 41046NY0010021 41046NY0010004 41046NY0010024

1.5 Metal Catastrophic Catastrophic Bronze Bronze Bronze Bronze Bronze Bronze Silver Silver Silver Silver Silver Silver Gold

1.6 AV Metal Value 0.618 0.618 0.634 0.634 0.634 0.634 0.634 0.634 0.720 0.720 0.720 0.720 0.720 0.720 0.809

1.7 Plan Category New New New New New New New New New New New New New New New

1.8 Plan Type HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO

1.9 Exchange Plan? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

1.10 Effective Date of Proposed Rates 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020

1.11 Cumulative Rate Change % (over 12 mos prior) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

1.12 Product Rate Increase %

1.13 Submission Level Rate Increase %

Worksheet 1 Totals Section II: Experience Period and Current Plan Level Information

2.1 Plan ID (Standard Component ID) Total 41046NY0010010 41046NY0010009 41046NY0010002 41046NY0010001 41046NY0010012 41046NY0010011 41046NY0010020 41046NY0010019 41046NY0010003 41046NY0010014 41046NY0010013 41046NY0010022 41046NY0010021 41046NY0010004 41046NY0010024

$0 2.2 Allowed Claims $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 2.3 Reinsurance $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2.4 Member Cost Sharing $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 2.6 Incurred Claims $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 2.7 Risk Adjustment Transfer Amount $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 2.8 Premium $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0 2.9 Experience Period Member Months 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2.10 Current Enrollment 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2.11 Current Premium PMPM #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

2.12 Loss Ratio #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Per Member Per Month

2.13 Allowed Claims #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.14 Reinsurance #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.15 Member Cost Sharing #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.16 Cost Sharing Reduction #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.17 Incurred Claims #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.18 Risk Adjustment Transfer Amount #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.19 Premium #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Section III: Plan Adjustment Factors

3.1 Plan ID (Standard Component ID) 41046NY0010010 41046NY0010009 41046NY0010002 41046NY0010001 41046NY0010012 41046NY0010011 41046NY0010020 41046NY0010019 41046NY0010003 41046NY0010014 41046NY0010013 41046NY0010022 41046NY0010021 41046NY0010004 41046NY0010024

3.2 Market Adjusted Index Rate

3.3 AV and Cost Sharing Design of Plan 0.5616 0.5616 0.5783 0.5783 0.6029 0.6029 0.2277 0.2277 0.7879 0.8210 0.8210 0.3159 0.3159 0.7879 0.4002

3.4 Provider Network Adjustment 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

3.5 Benefits in Addition to EHB 1.0660 1.0660 1.0276 1.0276 1.0264 1.0264 1.0700 1.0700 1.0202 1.0194 1.0194 1.0505 1.0505 1.0202 1.0398

Administrative Costs

3.6 Administrative Expense 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23%

3.7 Taxes and Fees 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76%

3.8 Profit & Risk Load 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73%

3.9 Catastrophic Adjustment 0.4300 0.4300 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

3.10 Plan Adjusted Index Rate $238.61 $238.61 $550.83 $550.83 $573.60 $573.60 $225.83 $225.83 $745.08 $775.77 $775.77 $307.60 $307.60 $745.08 $385.72

3.11 Age Calibration Factor 1.0000

3.12 Geographic Calibration Factor 1.0000

3.13 Tobacco Calibration Factor 1.0000

3.14 Calibrated Plan Adjusted Index Rate $238.61 $238.61 $550.83 $550.83 $573.60 $573.60 $225.83 $225.83 $745.08 $775.77 $775.77 $307.60 $307.60 $745.08 $385.72

Section IV: Projected Plan Level Information

4.1 Plan ID (Standard Component ID) Total 41046NY0010010 41046NY0010009 41046NY0010002 41046NY0010001 41046NY0010012 41046NY0010011 41046NY0010020 41046NY0010019 41046NY0010003 41046NY0010014 41046NY0010013 41046NY0010022 41046NY0010021 41046NY0010004 41046NY0010024

4.2 Allowed Claims $209,320,566 $1,754,897 $0 $39,613,992 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $75,703,870 $0

4.3 Reinsurance $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

4.4 Member Cost Sharing $32,888,880 $612,148 $0 $12,562,963 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $12,505,930 $0

4.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

4.6 Incurred Claims $176,431,686 $1,142,749 $0 $27,051,029 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $63,197,941 $0

4.7 Risk Adjustment Transfer Amount ‐$46,224 ‐$299 $0 ‐$7,087 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ‐$16,557 $0

4.8 Premium $204,556,459 $1,325,001 $0 $31,363,037 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $73,272,465 $0

4.9 Projected Member Months 256,800 5,553 0 56,936 0 0 0 0 0 0 0 0 0 0 98,338 0

4.10 Loss Ratio 86.27% 86.26% #DIV/0! 86.27% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 86.27% #DIV/0!

Per Member Per Month

4.11 Allowed Claims $815.11 $316.03 #DIV/0! $695.76 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $769.83 #DIV/0!

4.12 Reinsurance $0.00 $0.00 #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0!

4.13 Member Cost Sharing $128.07 $110.24 #DIV/0! $220.65 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $127.17 #DIV/0!

4.14 Cost Sharing Reduction $0.00 $0.00 #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0!

4.15 Incurred Claims $687.04 $205.79 #DIV/0! $475.11 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $642.66 #DIV/0!

4.16 Risk Adjustment Transfer Amount ‐$0.18 ‐$0.05 #DIV/0! ‐$0.12 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ‐$0.17 #DIV/0!

4.17 Premium $796.56 $238.61 #DIV/0! $550.85 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $745.11 #DIV/0!

Product/Plan Level Calculations

HMO On Exchange

41046NY001

0.00%

ton or Ctrl + Shift + P.

Ctrl + Shift + L.

HealthPlus

Gatekeeper X,

Gold, ST, INN,

Pediatric Dental,

Dep 25

HealthPlus

Gatekeeper X,

Gold, ST, INN,

Pediatric Dental,

Dep 25

HealthPlus

Gatekeeper X,

Gold, ST, INN,

Pediatric Dental,

Dep 29

HealthPlus

Gatekeeper X,

Gold Child Only,

ST, INN, Pediatric

Dental

HealthPlus

Gatekeeper X,

Gold, ST, INN,

Pediatric Dental,

Dep 29

HealthPlus

Gatekeeper X,

Platinum, ST, INN,

Pediatric Dental,

Dep 25

HealthPlus

Gatekeeper X,

Platinum, ST, INN,

Pediatric Dental,

Dep 25

HealthPlus

Gatekeeper X,

Platinum, ST, INN,

Pediatric Dental,

Dep 29

HealthPlus

Gatekeeper X,

Platinum, ST, INN,

Pediatric Dental,

Dep 29

HealthPlus

Gatekeeper X,

Platinum Child

Only, ST, INN,

Pediatric Dental

HealthPlus

Gatekeeper X,

Platinum Child

Only, ST, INN,

Pediatric Dental

HealthPlus

Gatekeeper for

HSA, Bronze, ST,

INN, Pediatric

Dental, Child Only,

SNF

HealthPlus

Gatekeeper for

HSA, Bronze, ST,

INN, Pediatric

Dental, Child Only,

SNF

HealthPlus

Gatekeeper for

HSA, Bronze, ST,

INN, Pediatric

Dental, Dep 25,

SNF

HealthPlus

Gatekeeper for

HSA, Bronze, ST,

INN, Pediatric

Dental, Dep 25,

SNF

HealthPlus

Gatekeeper for

HSA, Bronze, ST,

INN, Pediatric

Dental, Dep 29,

SNF

HealthPlus

Gatekeeper for

HSA, Bronze, ST,

INN, Pediatric

Dental, Dep 29,

SNF

HealthPlus

Gatekeeper, Silver

Child Only, ST,

INN, Pediatric

Dental, SNF

HealthPlus

Gatekeeper, Silver

Child Only, ST,

INN, Pediatric

Dental, SNF

HealthPlus

Gatekeeper, Silver,

ST, INN, Pediatric

Dental, Dep 25,

SNF

41046NY0010006 41046NY0010005 41046NY0010016 41046NY0010023 41046NY0010015 41046NY0010008 41046NY0010007 41046NY0010018 41046NY0010017 41046NY0010026 41046NY0010025 41046NY0020008 41046NY0020007 41046NY0020010 41046NY0020009 41046NY0020011 41046NY0020012 41046NY0020006 41046NY0020005 41046NY0020014

Gold Gold Gold Gold Gold Platinum Platinum Platinum Platinum Platinum Platinum Bronze Bronze Bronze Bronze Bronze Bronze Silver Silver Silver

0.809 0.809 0.809 0.809 0.809 0.887 0.887 0.887 0.887 0.887 0.887 0.634 0.634 0.634 0.634 0.634 0.634 0.720 0.720 0.720

New New New New New New New New New New New New New New New New New New New New

HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No

1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%


$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!









0.9894 0.9894 1.0307 0.4002 1.0307 1.2067 1.2067 1.2569 1.2569 0.4913 0.4913 0.2279 0.2279 0.5787 0.5787 0.6034 0.6034 0.3162 0.3162 0.7885

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

1.0161 1.0161 1.0155 1.0398 1.0155 1.0132 1.0132 1.0127 1.0127 1.0325 1.0325 1.0700 1.0700 1.0276 1.0276 1.0264 1.0264 1.0504 1.0504 1.0202

7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23%

5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76%

0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

$931.86 $931.86 $970.19 $385.72 $970.19 $1,133.28 $1,133.28 $1,179.85 $1,179.85 $470.20 $470.20 $226.03 $226.03 $551.22 $551.22 $574.07 $574.07 $307.87 $307.87 $745.64

$931.86 $931.86 $970.19 $385.72 $970.19 $1,133.28 $1,133.28 $1,179.85 $1,179.85 $470.20 $470.20 $226.03 $226.03 $551.22 $551.22 $574.07 $574.07 $307.87 $307.87 $745.64


$45,448,057 $0 $0 $0 $0 $46,799,750 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$4,871,461 $0 $0 $0 $0 $2,336,377 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$40,576,595 $0 $0 $0 $0 $44,463,372 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

‐$10,631 $0 $0 $0 $0 ‐$11,649 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$47,044,615 $0 $0 $0 $0 $51,551,341 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

50,485 0 0 0 0 45,488 0 0 0 0 0 0 0 0 0 0 0 0 0 0

86.27% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 86.27% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$900.23 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,028.84 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!




‐$0.21 #DIV/0! #DIV/0! #DIV/0! #DIV/0! ‐$0.26 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$931.85 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,133.30 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1.0000

1.0000

$799.75

0.00%

1.0000

HealthPlus

Gatekeeper, Silver,

ST, INN, Pediatric

Dental, Dep 29,

SNF

HealthPlus

Gatekeeper, Silver,

ST, INN, Pediatric

Dental, Dep 29,

SNF

HealthPlus

Gatekeeper, Silver,

ST, INN, Pediatric

Dental, Dep 25,

SNF

HealthPlus

Gatekeeper, Gold

Child Only, ST,

INN, Pediatric

Dental, SNF

HealthPlus

Gatekeeper, Gold

Child Only, ST,

INN, Pediatric

Dental, SNF

HealthPlus

Gatekeeper, Gold,

ST, INN, Pediatric

Dental, Dep 25,

SNF

HealthPlus

Gatekeeper, Gold,

ST, INN, Pediatric

Dental, Dep 25,

SNF

HealthPlus

Gatekeeper, Gold,

ST, INN, Pediatric

Dental, Dep 29,

SNF

HealthPlus

Gatekeeper, Gold,

ST, INN, Pediatric

Dental, Dep 29,

SNF

HealthPlus

Gatekeeper,

Platinum Child

Only, ST, INN,

Pediatric Dental,

SNF

HealthPlus

Gatekeeper,

Platinum Child

Only, ST, INN,

Pediatric Dental,

SNF

HealthPlus

Gatekeeper,

Platinum, ST, INN,

Pediatric Dental,

Dep 25, SNF

HealthPlus

Gatekeeper,

Platinum, ST, INN,

Pediatric Dental,

Dep 25, SNF

HealthPlus

Gatekeeper,

Platinum, ST, INN,

Pediatric Dental,

Dep 29, SNF

HealthPlus

Gatekeeper,

Platinum, ST, INN,

Pediatric Dental,

Dep 29, SNF

41046NY0020015 41046NY0020016 41046NY0020013 41046NY0020002 41046NY0020001 41046NY0020018 41046NY0020017 41046NY0020020 41046NY0020019 41046NY0020004 41046NY0020003 41046NY0020022 41046NY0020021 41046NY0020024 41046NY0020023

Silver Silver Silver Gold Gold Gold Gold Gold Gold Platinum Platinum Platinum Platinum Platinum Platinum

0.720 0.720 0.720 0.809 0.809 0.809 0.809 0.809 0.809 0.887 0.887 0.887 0.887 0.887 0.887

New New New New New New New New New New New New New New New

HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO

No No No No No No No No No No No No No No No

1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%


$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!









0.8216 0.8216 0.7885 0.4005 0.4005 0.9901 0.9901 1.0315 1.0315 0.4917 0.4917 1.2075 1.2075 1.2578 1.2578

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

1.0194 1.0194 1.0202 1.0398 1.0398 1.0161 1.0161 1.0155 1.0155 1.0324 1.0324 1.0132 1.0132 1.0127 1.0127

7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23% 7.23%

5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76% 5.76%

0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73% 0.73%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

$776.34 $776.34 $745.64 $386.01 $386.01 $932.52 $932.52 $970.94 $970.94 $470.54 $470.54 $1,134.03 $1,134.03 $1,180.69 $1,180.69

$776.34 $776.34 $745.64 $386.01 $386.01 $932.52 $932.52 $970.94 $970.94 $470.54 $470.54 $1,134.03 $1,134.03 $1,180.69 $1,180.69


$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0









HMO Off Exchange

41046NY002

0.00%

Rating Area Data Collection Specify the total number of Rating Areas in your State by selecting the Create Rating Areas button or Ctrl + Shift + R.If macros are disabled, press and hold the ALT key and press the F, thenSelect only the Rating Areas you are offering plans within and add a factor for each area.

To validate, select the Validate button or Ctrl + Shift + I.To finalize, select the Finalize button or Ctrl + Shift + F.

Rating Area Rating Factor

Rating Area 1 0.8881





Filing at a Glance - DFS Portal...Filing at a Glance Company: HealthPlus HP, LLC Product Name:...

Documents

Transcript of Filing at a Glance - DFS Portal...Filing at a Glance Company: HealthPlus HP, LLC Product Name:...