2015 Federated Small Group Rate Filing.pdf

ActuarialMemorandumRateFilingforFederatedMutualInsuranceCompany

StateofMissouriSmallGroupPolicyForm#:GH2410(0114ed.)

1.GeneralInformationCompanyIdentifyingInformation

CompanyLegalName:FederatedMutualInsuranceCompanyState:MissouriHIOSIssuerID:64701Market:SmallGroupEffectiveDate:January1,2015

CompanyContactInformationPrimaryContactName:JaniceKautzPrimaryContactTelephoneNumber:8005330472ext.5129PrimaryContactEmail:[email protected]

MarketSmallGroupMarket

DescriptionofBenefitsTheformlistedaboveisaPreferredProviderOrganization(PPO)healthinsuranceproductmarketedtosmallemployers(1to50employees).Benefitsarecomprehensiveinnature,andincludeprescriptiondrugs.Acompletelistingoftheplanoptionsfordeductible,coinsurance,outofpocketmaximumandcopaymentisshowninAttachmentAofthismemorandum.

MarketingMethodFederatedmarketsthroughitsowndirectsalesforce,whichfocusesonsmallercompaniesinselecttypesofbusiness.

2.ProposedRateChangeReasonforRateChange

ThepurposeofthismemorandumistofileratesandbenefitplansincompliancewiththePatientProtectionandAffordableCareAct(PPACA)andtoproposearateincreaseforFederatedMutualInsuranceCompany's(Federated)PolicyFormGH2410(0114ed.).TheratesinthisfilingwillapplytonewandrenewalbusinessontheaboveformonorafterJanuary1,2015.Federatedisalsoproposingannualtrendadjustmentsof4.00%.

FortheStateofMissouri,theproposedratesareanincreaseof6.1%fromcurrentratelevels.Theratechangeisdrivenbyclaimcostexperience,projectedtrend,assumeddiscountlevelsandtheimpactofACARiskAdjustment.Theratechangewillvarybyratingareaandplan.

Basedonastudyperformedforusbyanexternalconsultant,theproposedratechangeincludesanassumedcostof7.0%duetoRiskAdjustment.Basedon2015experience,weareassumingapaymentintotheRiskAdjustmentprogram.

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3.ExperiencePeriodPremiumandClaimsPaidThroughDate

Theclaimsincludedintheexperienceperiod,January1,2013throughDecember31,2013,includeallclaimsincurredintheStateofMissouriduringtheexperienceperiodandpaidthroughMarch31,2014plusanestimateofincurredbutnotpaidclaims.

Premiums(netofMLRRebate)inExperiencePeriodPremiumsintheexperienceperiodwereobtainedatagrouplevelfromaninternaldatasystem.SincenoMLRrebateswerepaidinMissouriduringtheexperienceperiod,earnedpremiumbeforeandnetofMLRadjustmentsis$23,965,909.

AllowedandIncurredClaimsIncurredDuringtheExperiencePeriodClaimswereobtainedfromclaimrecordsstoredinaninternaldatasystem.AllmedicalclaimsareprocessedthroughFederatedsystems.PharmacyclaimsareprocessedoutsidethesystembyaPharmacyBenefitManager(PBM).

ClaimsthathavebeenincurredbutnotreportedareestimatedusingacompletionfactorapproachbasedonFederatedsentireblockofgroupmedicalbusiness.Thisapproachusestraditionalactuarialpracticestoaccountforhistoriccompletionpatternsandunusual(onetime)events.Reservesfortheexperienceperiodwereneitherunusuallyhighnorunusuallylow.

Federatedsblockofgroupmedicalbusinessconsistsofsimilarproductsofferedintwentythreestates.Ratesontheseproductshavebeencalculatedtobeactuariallyequivalentandexperiencefromtheseproductshasalwaysbeencombinedforreservingpurposes.Thecompletionpatternoftheblockofbusinessisassumedtobeconsistentwiththeproductsincludedintheexperienceforthisfiling.

Duetothesmallamountofexperienceincludedinthisfiling,completionfactorsareappliedtotheblockclaimstoestimateablockreserveswhichisthenallocatedtoportionsofthebusiness.

Paidandallowedclaimreservesareallocatedbasedonearnedpremium.

4.BenefitCategoriesThebenefitcategoriesforURRTWorksheet1wereassignedtoclaimsbasedonthefollowingmethodology:

InpatientHospitalFacilityandaccommodationchargesthatappearonan837IorUBwithanaccommodationcharge.

OutpatientHospitalFacilitychargesthatappearonan837IorUBwithoutanaccommodationcharge.

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OtherMedicalChargessubmittedonand837PorHCFAbillforAmbulanceServices,Dental,DurablemedicalEquipment,HomeHealthCare,MedicalSupplies,ProstheticsorOrthotics.

ProfessionalProviderchargesthatappearon837PorHCFAthatarenotincludedforservicescoveredunderOtherMedical.

PrescriptionDrugChargesprocessedbyaPBMforprescriptiondrugsdispensedbynetworkpharmaciesandchargesforprescriptiondrugsdispensedinaprofessional,inpatientoroutpatientsettingwithlineitembilling.

CapitationTherewerenocapitationagreementsinplaceduringtheexperienceperiod.Nocapitationagreementsareanticipatedfortheprojectedperiod.

Forchargesthatarecombinedintoasinglefee,eitherbasedontheproviderbillingornetworkratenegotiationsthechargesareunabletobesplitintofacilityandprofessionalcomponents.Inthesecasesallchargesareassignedtothefacilitycategory,InpatientHospitalorOutpatientHospital.

5.ProjectionFactorsChangesintheMorbidityofthePopulationInsured

Thelossofunderwritingcombinedwithguaranteedissuerequirementsareexpectedtoincreasetheaveragepermemberclaimcostwithinthesmallgroupmarket.Federatedexpectsthesechangestohavesimilareffectsonitssmallgrouppopulationasonthesmallgroupmarketasawhole.

Theincreaseinmorbiditywasestimatedusingunderwritingresultsandactuarialjudgment.Theitemsconsideredintheadjustmentwere:lossofunderwritingandthemorbidityimpactduetothetransitionalreliefoption.

ChangesinBenefitsAdditionalbenefitsforhabilitativecare,rehabilitativecareandpediatricvisionduetoEssentialHealthBenefitrequirementsandthecoverageofbenefitsforpreexistingconditionswillbeprovided.

Federatedinternalanalysis,historicalclaimdenialsandactuarialjudgmentwereusedtoestimatetheimpactofthesebenefits.

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ChangesinDemographicsAdjustmentsweremadetothedataforageanddurationtobringthesingleriskpooldatatothelevelofournationwideblock.AsanewproductitisexpectedthattheagemixturewillbesimilartothatoftheFederatednationwidepopulation.Thefederalagefactorswereusedforthisadjustmentasthosewillbereflectiveofpremiumdifferenceinthefuture.

OtherAdjustmentsAlldataisbasedonallowedchargeswhichreflectprovidercontractingofmultiplePPOnetworks.AnadjustmentwasmadetodatawheretheunderlyingdiscountsbasedonthemixofPPOsinthedatawasdifferentfromtheexpecteddiscountsduringtheprojectionperiod.TheadjustmentwasmadeapplyingthedifferencetotheallowedclaimsexperiencebycomparingtherelativecostsofthePPOsinthedatawiththeexpecteddistributionofmembershipandprojectednetworkcostlevels.

Theconsiderationsforthe"OtherAdjustments"included:removalofpreexistingconditionlimits,additionalbenefitsduetoEHBrequirementscomparedtotheexperienceperiod(nonACAexperience),changestothePharmacyBenefitsManager,adjustmentsduetochangesinPPOdiscounts,poolingchargesforthecategoryandtheadditionalcostofoutofnetworkbenefits.

TrendFactorsFederatedcalculatestrendinternally,basedonhistoricalnationwideclaimresults.Separateestimatesaremadeformedicalandpharmacyclaims,withadjustmentsforlargeclaims.

Historicaltrendsarecalculatedbasedonallowedcharges,permemberpermonth.Claimsareadjustedforseasonalityandforonetimeevents,suchastherenegotiationofapharmacycontract.

Basedontheresultsofthisstudy,Federatedisestimatinganannualcosttrendof4.0%incombinedmedicalandpharmacyallowedcosts.Noaggregatetrendisassumedforunderwritingwearofforantiselection.

Thetrendimpactwillberecognizedonaquarterlybasis.TheeffectofthetrendincreasesontheindexrateisshownonAttachmentB.

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Thetrend,bycategory,is:Inpatient:3.0%(weightof22%)Outpatient:4.0%(weightof32%)Professional:3.5%(weightof28%)PBMPharmacy:5.0%(weightof15%)nonPBMPharmacy:10.0%(weightof1%)Other:10%(weightof2%)

TotalTrend:4.0%

6.CredibilityManualRateDevelopmentSourceandAppropriatenessofExperienceDataUsed

Federatedcurrentlysellsaproductsimilartotheoneintheexperienceperiodintwentythreestates.RatesonallofFederatedssmallgrouphealthinsuranceplansarecalculatedtobeactuariallyequivalent.Experienceonallsmallgroupformshasalwaysbeencombinedforratingpurposes.

Federatedassumesthatitsnationwideexperienceiscredible,butthatstatespecificexperiencemaynotbeso.Federatedusedexternalconsultantdatatoassistinestablishingstateandarealeveladjustmentfactorsinthedevelopmentofmanualrates.

Claimsaredividedintofiveservicecategories:InpatientHospital,OutpatientHospital,PhysicianServices,PrescriptionDrugs,andOthercharges.Foreachofthesecategories,AllowedChargespermember,permonth(PMPM)werecalculatedonbothastatespecificandanationwidebasis,fortheexperienceperiodof1/1/2013through12/31/2013.

AdjustmentsMadetotheDataAlldataisbasedonallowedchargeswhichreflectprovidercontractingofmultiplePPOnetworks.AnadjustmentwasmadetodatawheretheunderlyingdiscountsbasedonthemixofPPOsinthedatawasdifferentfromtheexpecteddiscountsduringtheprojectionperiod.TheadjustmentwasmadeapplyingthedifferencetotheallowedclaimsexperiencebycomparingtherelativecostsofthePPOsinthedatawiththeexpecteddistributionofmembershipandprojectednetworkcostlevels.Additionalbenefitsforhabilitativecare,rehabilitativecareandpediatricvisionduetoEssentialHealthBenefitrequirementsandthecoverageofbenefitsforpreexistingconditionswillbeprovided.Theincreaseinmorbiditywasestimatedusingunderwritingresultsandactuarialjudgment.

InclusionofCapitationPaymentsFederateddoesnotusecapitationpayments.Noneareincludedintheratedevelopment.

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7.CredibilityofExperienceDescriptionofCredibilityMethodologyUsed

Thenationwidecappedchargesareusedtodeterminethemembermonthsneededtodeterminethecredibilitylevelforeachprimaryservicecategory,ineachstate.Foreachprimaryservicecategory,themembermonthsneededforfullcredibilityaredeterminedbytheequation:

ThederivationofwhichcanbefoundinthepaperAnIntroductiontoCredibilityTheorybyL.H.LongleyCook,whichcanbefoundontheinternetathttp://www.casact.org/pubs/proceed/proceed62/62194.pdf.

Foreachprimarycategory,credibilityiscalculatedas:

withamaximumcredibilityof1.000.ThedeterminationofcredibilitybyprimaryservicecategoryisshowninAttachmentC.

Foreachprimaryservicecategory,thecappedallowedchargesPMPMarecomparedtoFederatedsnationwideallowedchargesPMPMbyprimaryservicecategory,andcredibilityisapplied(ifnecessary)byusingthefollowingequation:

Theresultingvalue(summedforallprimaryservicecategories)iscomparedtotheoriginalcalculationofallowedchargespermember,permonth.Theratioofthesetwovaluesisappliedtoactualpaidclaims,asthecredibilityadjustmentinthebaselossratiocalculation.

8.PaidtoAllowedRatioThepaidtoallowedratiobyplanisshowninAttachmentF.

9.RiskAdjustmentandReinsuranceProjectedRiskAdjustmentsPMPM

FortheStateofMissouri,theproposedratesareanincreaseof6.1%fromcurrentratelevels.Theratechangeisdrivenbyclaimcostexperience,projectedtrend,assumeddiscountlevelsandtheimpactofACARiskAdjustment.Theratechangewillvarybyratingareaandplan.

Factory Credibilit - 100% PMPM Charges Allowed Nationwide

Factory Credibilit PMPM Charges Allowed Capped Specific-State PMPM Charges Allowed edCredibiliz

2PMPM Charges Allowed Capped ofMean PMPM Charges Allowed Capped of Variance1082,1

yCredibilit Fullfor Needed MonthsMember Period Experience theduring MonthsMember Specific-State

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Basedonastudyperformedforusbyanexternalconsultant,theproposedratechangeincludesanassumedcostof7.0%duetoRiskAdjustment.Basedon2015experience,weareassumingapaymentintotheRiskAdjustmentprogram.

ProjectedACAReinsuranceRecoveriesNetofReinsurancePremiumReinsurancerecoveriesareexpectedtobe$0astherecoveriesareonlyavailableintheindividualmarket.Thereinsurancepremiumof$3.67PMPMisincluded.

10.NonBenefitExpensesandProfit&RiskAdministrativeExpenseLoad

Administrativeexpenses(notincludingtaxes)areassumedtobe14.7%ofpremiumintheprojectionperiod.Thepercentageloaddoesnotvarybyproductorplanandisnotallocatedonaperpolicybasis.

Federatedmarketsitsgrouphealthproductsthroughitsowndirectsalesforceanddoesnotuseindependentagentsorbrokers.Salescommissionswere1.2%ofpremium.

Profit(orContributiontoSurplus)&RiskMarginFor2015,FederatedistargetingaContributiontoSurplusof3.0%inMissouri.Noadditionalriskmarginisincluded.

TaxesandFeesAlltaxesandfeesinMissouritotaled2.3%ofpremium.

For2015,Federatedassumesanadditional1.4%intaxesduetotheadditionaltaxesandfeesimposedbytheACA.

11.ProjectedLossRatioTheprojectedlossratio,onaMLRbasis,isshowninAttachmentD.

12.SingleRiskPoolThesingleriskpoolsmallgroupplanswereestablishedinaccordancewiththerequirementsof45CFRpart156,156.80(d).ThesingleriskpoolreflectscoveredlivesinallnongrandfatheredproductssoldintheStateofMissourismallgroupmarket.ProjectedvaluesreflectexperienceformembersinnonACAcompliantplansduringthehistoricalperiod,totheextenttheyareanticipatedtobeinACAcompliantplansduringtheprojectionperiod.

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13.IndexRateTheindexratefortheexperienceperiodistheallowedclaimspermemberpermonthforthesingleriskpoolconsistingofFederatedssmallgroupbusinessduringthisperiod.Adjustmentsweremadetothisrate,asdescribedaboveintheProjectionFactorsandtheCredibilityManualRateDevelopmentsections,tomovetheexperienceperiodratetotheprojectionperiodindexrate.

TheindexrateintheprojectionperiodistheexpectedallowedclaimspermemberpermonthforFederatedssingleriskpoolforsmallgrouppoliciesinMissouri.TheclaimshavebeenadjustedforquarterlytrendincreasesandtheaverageisweightedontheprojectedmembershipasshowninAttachmentB.NofurtheradjustmentstotheexpectedclaimsweremadeforbenefitsasthispolicyformiscoveringnobenefitsinexcessofEHB.

Planratelevelscanbederivedfromtheprojectedindexratebyadjustingforplandesignandcostsharingcharacteristics,asshownintheAVPricingsectionbelow,andexpectedexpense.Forindividuals,theseratesarefurtheradjustedbasedontheindividualsage(usingthefederallyprescribedagecurve),thegeographicarea,andanticipatedprovidernetworkcostdifferences.

14.MarketAdjustedIndexRateTheMarketAdjustedIndexratewascalculatedastheIndexRateadjustedforallallowablemarketwidemodifiersasdefinedinthemarketratingrules,45CFRPart156,156.80(d)(1).Theadjustmentsmayinclude:FederalReinsuranceProgramFeesandRiskAdjusterFees.

15.PlanAdjustedIndexRatesPlanadjustedindexratesreflecttheMarketAdjustedIndexRateadjustedforallowableplanlevelmodifiersdefinedinthemarketratingrules,45CFRPart156,156.80(d)(2).Theseadjustmentsmayinclude:planactuarialvalueandcostsharingvaluefactor,benefitsundertheplaninadditiontoEHB,distributionandadministrativecostsandtheplanprovidernetwork,deliverysystemcharacteristicsandutilizationmanagementpractices.

16.CalibrationAttachmentGprovidesanillustrationforthedevelopmentoftheapplicablecalibrationfactorsforageandgeographicarea.

17.ConsumerAdjustedPremiumRateDevelopmentAttachmentAprovidesanillustrationforthedevelopmentofconsumeradjustedpremiumratesforsampleinsuredmembers.The"IndividualRate"istheConsumerAdjustedPremiumRate.

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18.AVMetalValuesAllAVMetalValuesshowninWorksheet2ofthePart1UnifiedRateReviewTemplatewereentirelybasedontheAVCalculatordevelopedandmadeavailablebyHHS.

19.AVPricingValuesTheAVPricingValuesforeachProductIDareinWorksheet2,SectionIoftheUnifiedRateReviewTemplate.ThedevelopmentoftheAVPricingvaluesisshowninAttachmentG.ConsistentwithfinalMarketrules,utilizationadjustmentsaremadetoaccountformemberbehaviorvariationsbaseduponcostsharevariationsofthebenefitdesignandnotthehealthstatusofthemember.ThebehaviormodificationsarebasedontheamountsdevelopedwithintheAVCalculator.

20.MembershipProjectionsMembershipprojectionsarebasedon10%ofmembersonnonACAcompliantplansmovingtoACAcompliantplansalongwithadditionalmembershipfromnewsalesduringtheyear.Newsaletargetsarebasedonhistoricalproduction.

Enrollmentbymetaltierisbasedonhistoricaldistribution.Enrollmentbetweentheplanswithinametaltieraredistributedevenlyforagivennetwork.

21.TerminatedProductsNoproductswillbeterminated.

22.PlanTypeFormGH2410(0114ed.)isaPPOproductasselectedinWorksheet2Section1oftheURRT.Nofurtherdescriptionisnecessary.

23.WarningAlertsNone

24.EffectiveRateReviewInformationRates

RateFactors,includinggeographicareadefinitionsandcostsharingvariations,areshowninAttachmentA.

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ProjectedAveragePremiumTheprojectedaveragepremiumfornewPolicyFormGH2410(0114ed.)inMissouriis$293.75permemberpermonth.Thecurrentaveragepremiumpermemberpermonthontheformis$276.97.

Therearecurrently386membersonthisforminMissourionMay1,2014.

CompanyFinancialConditionRiskBasedCapital:FederatedMutualisprimarilyaproperty/casualtyinsurancecompany.Healthinsuranceisapproximately30%ofpremiums.Overall,FederatedsRBCisapproximately1,871%ofAuthorizedControlLevel.

CompanySurplus:AsofDecember31,2013,FederatedMutualInsuranceCompanyhadsurplusof$2.53billion.

RateGuaranteeThepremiumchargedwillnotbeadjustedmorefrequentlythanannuallyexceptthatthepremiumratemaybechangedtoreflectchangesto(i)familycompositionofthemember;or(ii)coveragerequestedbythemember.

RenewabilityFederatedoffersthisproductonaguaranteedrenewablebasis.

RateHistoryTherehavebeennopriorratechangesonthisform.

25.RelianceTheinformationcontainedinthismemorandumandtheURRTsubmissionwerecreatedwithrelianceoncalculations,assumptions,analysisandotherworkcompletedbytheinternalstaffofFederatedMutualInsuranceCompany,andassuchwasreliedonbythecertifyingActuary.Forareafactors,statefactorsandRiskAdjustment,wereliedontheworkperformedbyexternalconsultingfirms.

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26.ActuarialCertificationI,ScottD.Haglund,amamemberoftheAmericanAcademyofActuariesandmeettheQualificationStandardsoftheAcademytorendertheactuarialopinioncontainedherein.Icertify,tothebestofmyknowledgeandjudgment,:

TheratesproposedinthismemorandumareinfullcompliancewithallapplicableMissouristatutesandregulationsandtheapplicableFederalstatutesandregulations(45CFR154.215);TheproposedindexratewasdevelopedincompliancewithallapplicableActuarialStandardsofPractice;Theproposedratesarereasonableinrelaontothebenefitsprovidedandthepopulaonancipatedtobecovered;Thepremiumscheduleisnotexcessive,inadequate,norunfairlydiscriminatory;Theproposedratesareuniformlyappliedtohealthbenefitplanscoveringsmallemployers;

Theindexrateandonlytheallowablemodifiersasdescribedin45CFR156.80(d)(1)and45CFR156.80(d)(2)wereusedtogenerateplanlevelrates;

ThepercentoftotalpremiumthatrepresentsessenalhealthbenefitsincludedinWorksheet2,SectionsIIIandIVwascalculatedinaccordancewithactuarialstandardsofpractice;TheAVCalculatorwasusedtodeterminetheAVMetalValuesshowninWorksheet2ofthePartIUnifiedRateReviewTemplateforallplans;ThehealthbenefitplansprescripondrugbenefitcomplieswiththefinalruleonStandardsRelatedtoEssentialHealthBenefits,ActuarialValue,andAccreditation;

TheproposedratesweredevelopedincompliancewithallapplicableActuarialStandardsofPracce.

ThisopinionisqualifiedasthePartIUnifiedRateReviewTemplate(URRT)doesnotdemonstratetheprocessusedbytheissuertodeveloptherates.TheURRTrepresentsinformationrequiredbyFederalregulationtosupportthereviewofpremiumimpactsandforcertificationthattheindexrateisdevelopedinaccordancewithFederalregulationandusedconsistentlyandonlyadjustedbytheallowablemodifiers.

ScottD.Haglund,FSA,MAAAVicePresidentandDirector,ActuarialServicesLife&HealthFederatedMutualInsuranceCompany

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Actuarial MemorandumRate Filing for Federated Mutual Insurance Company

State of MissouriPolicy Form #: GH 24 10 (01-14 ed.)

Attachment A - Consumer Adjusted Index Rate

Effective Date Trend Sample Rate Calculation

01/01/2015 1.0000 As of 01/01/2015

04/01/2015 1.0099 Plan 1409A x $294.14

07/01/2015 1.0198 Age 40 x 1.278

10/01/2015 1.0299 $375.91

Tobacco Use* x 1.000

$375.91 Maximum of 3 children under 21 yrs.

Geo Rating Area 4 x 1.040 charged per family

Individual Rate $390.94

Plan Metal Level Premium Plan Metal Level Premium Plan Metal Level Premium Age Age Tobacco

1401A Platinum 330.64$ 1401C Platinum 322.76$ 1401E Platinum 258.90$ Band Factor Factor

1402A Gold 290.72$ 1402C Gold 281.55$ 1402E Gold 236.13$ 0-17 0.635 1.00

1403A Gold 292.74$ 1403C Gold 278.31$ 1403E Gold 339.12$ 18 0.635 1.00

1404A Silver 255.36$ 1404C Silver 253.84$ 1404E Silver 306.19$ 19 0.635 1.00


1406A Bronze 230.22$ 1406C Bronze 329.15$ 1406E Bronze 300.70$ 21 1.000 1.00

1407A Platinum 330.64$ 1407C Platinum 324.31$ 1407E Platinum 265.38$ 22 1.000 1.00




























1401B Platinum 252.50$ 1401D Platinum 291.69$ 50 1.786 1.00

1402B Gold 304.49$ 1402D Gold 288.44$ 51 1.865 1.00

1403B Gold 264.56$ 1403D Gold 253.84$ 52 1.952 1.00

1404B Silver 261.61$ 1404D Silver 237.46$ 53 2.040 1.00

1405B Silver 230.22$ 1405D Silver 335.54$ 54 2.135 1.00

1406B Bronze 215.37$ 1406D Bronze 332.35$ Geographic Factors 55 2.230 1.00

1407B Platinum 304.33$ 1407D Platinum 321.06$ Area Factor 56 2.333 1.00

1408B Gold 301.43$ 1408D Gold 288.44$ Rating Area 1 0.980 57 2.437 1.00



1411B Silver 252.89$ 1411D Silver 294.78$ Rating Area 4 1.040 60 2.714 1.00




1415B Bronze 215.37$ 1415D Bronze 339.12$ Rating Area 8 0.960 64+ 3.000 1.00

1416B Platinum 226.01$ 1416D Platinum 298.18$ Rating Area 9 1.010

1417B Gold 364.56$ 1417D Gold 300.24$ Rating Area 10 1.000

1418B Silver 320.54$ 1418D Silver 261.91$

1501B Platinum 258.90$ 1501D Platinum 300.24$

1502B Gold 236.13$ 1502D Gold 261.91$

1503B Gold 339.12$ 1503D Gold 258.90$ Network A is available statewide

1504B Silver 306.19$ 1504D Silver 236.13$

1505B Silver 301.68$ 1505D Silver 339.12$ Network B is available in Rating Areas 1, 4, 5, and 7 - 9

1506B Bronze 300.70$ 1506D Bronze 306.19$

1507B Platinum 265.38$ 1507D Platinum 301.68$ Network C is avaliable in Rating Areas 2 and 4 - 10

1508B Gold 303.21$ 1508D Gold 300.70$

1509B Gold 262.40$ 1509D Gold 265.38$ Network D is avaliable in Rating Areas 3, 4, and 7 - 9

1510B Gold 262.46$ 1510D Gold 303.21$

1511B Silver 220.89$ 1511D Silver 262.40$ Network E is avaliable in Rating Areas 1, 3 - 5, 7, and 8

1512B Gold 336.15$ 1512D Gold 262.46$

1513B Silver 300.24$ 1513D Silver 220.89$

1514B Silver 261.60$ 1514D Silver 336.15$

1515B Bronze 258.98$ 1515D Bronze 300.24$

1516B Platinum 312.30$ 1516D Platinum 261.60$

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Attachment A - Plan Designs

Plan Name Metal Level Network Deductible OON - DeductibleFamily

DeductibleOON - Family

Deductible OOP Max OON - OOP Family OOP OON - Family OOP Coins OON - Coins OV Copay SpOV Copay Rx Emergency

1401A Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% $20 $20 10/30/60/150 $1001402A Gold A $1,000 $1,000 $2,000 $2,000 $4,000 $8,000 $8,000 $16,000 85% 60% $40 $40 12/40/70/175 $2001403A Gold A $600 $600 $1,200 $1,200 $4,600 $9,200 $9,200 $18,400 80% 55% 12/40/70/1751404A Silver A $1,500 $1,500 $3,000 $3,000 $5,500 $8,250 $11,000 $16,500 70% 50% 16/60/90/2251405A Silver A $2,000 $2,000 $4,000 $4,000 $5,500 $9,875 $11,000 $19,750 80% 55% 16/60/90/2251406A Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% 20/80/120/3001407A Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% 15% 15% 10/30/60/150 15%1408A Gold A $500 $500 $1,000 $1,000 $5,000 $7,500 $10,000 $15,000 70% 50% 20% 20% 12/40/70/175 20%1409A Gold A $1,000 $1,000 $2,000 $2,000 $5,500 $11,000 $11,000 $22,000 80% 55% 20% 20% 12/40/70/175 20%1410A Gold A $1,500 $1,500 $3,000 $3,000 $4,500 $8,250 $9,000 $16,500 80% 55% 20% 20% 12/40/70/175 20%1411A Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% 35% 35% 16/60/90/225 35%1412A Gold A $1,300 $1,300 $2,600 $2,600 $2,500 $4,500 $5,000 $9,000 85% 60% Deduct./Coins.; Specialty max $1751413A Silver A $1,750 $1,750 $3,500 $3,500 $5,000 $7,500 $10,000 $15,000 70% 50% Deduct./Coins.; Specialty max $2251414A Silver A $2,000 $2,000 $4,000 $4,000 $6,000 $11,000 $12,000 $22,000 80% 55% Deduct./Coins.; Specialty max $2251415A Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% Deduct./Coins.; Specialty max $3001416A Platinum A $0 $0 $0 $0 $1,500 $3,000 $3,000 $6,000 80% 55% $20 $20 10/30/60/150 $1501417A Gold A $1,000 $1,000 $2,000 $2,000 $3,450 $7,000 $6,900 $14,000 80% 55% $40 $40 12/40/70/175 $2001418A Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% $50 $50 16/60/90/225 $4001501A Silver A $3,000 $3,000 $6,000 $6,000 $6,600 $13,200 $13,200 $26,400 80% 60% $40 $300 16/60/90/225 $3001502A Gold A $0 $0 $0 $0 $3,200 $12,800 $6,400 $25,600 50% 50% 12/40/70/1751503A Silver A $0 $0 $0 $0 $6,600 $13,200 $13,200 $26,400 50% 50% 16/60/90/2251504A Silver A $3,000 $3,000 $6,000 $6,000 $4,500 $9,000 $9,000 $18,000 80% 60% 3free 16/60/90/2251505A Bronze A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 25/95/150/3001506A Bronze A $6,600 $6,600 $13,200 $13,200 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 20/80/120/3001507A Gold A $1,000 $1,000 $2,000 $2,000 $3,250 $6,500 $6,500 $13,000 80% 60% 20% 20% 12/40/70/175 20%1508A Gold A $2,000 $2,000 $4,000 $4,000 $3,000 $6,000 $6,000 $12,000 100% 75% 20% 20% 12/40/70/175 20%1509A Gold A $2,000 $2,000 $4,000 $4,000 $4,000 $8,000 $8,000 $16,000 80% 60% 20% 20% 12/40/70/175 20%1510A Silver A $3,500 $3,500 $7,000 $7,000 $6,250 $12,500 $12,500 $25,000 80% 60% 20% 20% 16/60/90/225 20%1511A Silver A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 80% 60% 20% 20% 16/60/90/225 20%1512A Silver A $2,750 $2,750 $5,500 $5,500 $3,750 $7,500 $7,500 $15,000 80% 60% Deduct./Coins.; Specialty max $2251513A Silver A $3,000 $3,000 $6,000 $6,000 $3,000 $6,000 $6,000 $12,000 100% 75% Deduct./Coins.; Specialty max $2251514A Bronze A $6,000 $6,000 $12,000 $12,000 $6,000 $12,000 $12,000 $24,000 100% 75% Deduct./Coins.; Specialty max $3001515A Bronze A $6,300 $6,300 $12,600 $12,600 $6,300 $12,600 $12,600 $25,200 100% 70% Deduct./Coins.; Specialty max $3001516A Bronze A $4,000 $4,000 $8,000 $8,000 $6,600 $13,200 $13,200 $26,400 70% 50% $60 $500 25/95/150/300 $500

MO-201501 A - 2 09/09/2014







1401B Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% $20 $20 10/30/60/150 $1001402B Gold A $1,000 $1,000 $2,000 $2,000 $4,000 $8,000 $8,000 $16,000 85% 60% $40 $40 12/40/70/175 $2001403B Gold A $600 $600 $1,200 $1,200 $4,600 $9,200 $9,200 $18,400 80% 55% 12/40/70/1751404B Silver A $1,500 $1,500 $3,000 $3,000 $5,500 $8,250 $11,000 $16,500 70% 50% 16/60/90/2251405B Silver A $2,000 $2,000 $4,000 $4,000 $5,500 $9,875 $11,000 $19,750 80% 55% 16/60/90/2251406B Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% 20/80/120/3001407B Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% 15% 15% 10/30/60/150 15%1408B Gold A $500 $500 $1,000 $1,000 $5,000 $7,500 $10,000 $15,000 70% 50% 20% 20% 12/40/70/175 20%1409B Gold A $1,000 $1,000 $2,000 $2,000 $5,500 $11,000 $11,000 $22,000 80% 55% 20% 20% 12/40/70/175 20%1410B Gold A $1,500 $1,500 $3,000 $3,000 $4,500 $8,250 $9,000 $16,500 80% 55% 20% 20% 12/40/70/175 20%1411B Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% 35% 35% 16/60/90/225 35%1412B Gold A $1,300 $1,300 $2,600 $2,600 $2,500 $4,500 $5,000 $9,000 85% 60% Deduct./Coins.; Specialty max $1751413B Silver A $1,750 $1,750 $3,500 $3,500 $5,000 $7,500 $10,000 $15,000 70% 50% Deduct./Coins.; Specialty max $2251414B Silver A $2,000 $2,000 $4,000 $4,000 $6,000 $11,000 $12,000 $22,000 80% 55% Deduct./Coins.; Specialty max $2251415B Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% Deduct./Coins.; Specialty max $3001416B Platinum A $0 $0 $0 $0 $1,500 $3,000 $3,000 $6,000 80% 55% $20 $20 10/30/60/150 $1501417B Gold A $1,000 $1,000 $2,000 $2,000 $3,450 $7,000 $6,900 $14,000 80% 55% $40 $40 12/40/70/175 $2001418B Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% $50 $50 16/60/90/225 $4001501B Silver A $3,000 $3,000 $6,000 $6,000 $6,600 $13,200 $13,200 $26,400 80% 60% $40 $300 16/60/90/225 $3001502B Gold A $0 $0 $0 $0 $3,200 $12,800 $6,400 $25,600 50% 50% 12/40/70/1751503B Silver A $0 $0 $0 $0 $6,600 $13,200 $13,200 $26,400 50% 50% 16/60/90/2251504B Silver A $3,000 $3,000 $6,000 $6,000 $4,500 $9,000 $9,000 $18,000 80% 60% 3free 16/60/90/2251505B Bronze A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 25/95/150/3001506B Bronze A $6,600 $6,600 $13,200 $13,200 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 20/80/120/3001507B Gold A $1,000 $1,000 $2,000 $2,000 $3,250 $6,500 $6,500 $13,000 80% 60% 20% 20% 12/40/70/175 20%1508B Gold A $2,000 $2,000 $4,000 $4,000 $3,000 $6,000 $6,000 $12,000 100% 75% 20% 20% 12/40/70/175 20%1509B Gold A $2,000 $2,000 $4,000 $4,000 $4,000 $8,000 $8,000 $16,000 80% 60% 20% 20% 12/40/70/175 20%1510B Silver A $3,500 $3,500 $7,000 $7,000 $6,250 $12,500 $12,500 $25,000 80% 60% 20% 20% 16/60/90/225 20%1511B Silver A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 80% 60% 20% 20% 16/60/90/225 20%1512B Silver A $2,750 $2,750 $5,500 $5,500 $3,750 $7,500 $7,500 $15,000 80% 60% Deduct./Coins.; Specialty max $2251513B Silver A $3,000 $3,000 $6,000 $6,000 $3,000 $6,000 $6,000 $12,000 100% 75% Deduct./Coins.; Specialty max $2251514B Bronze A $6,000 $6,000 $12,000 $12,000 $6,000 $12,000 $12,000 $24,000 100% 75% Deduct./Coins.; Specialty max $3001515B Bronze A $6,300 $6,300 $12,600 $12,600 $6,300 $12,600 $12,600 $25,200 100% 70% Deduct./Coins.; Specialty max $3001516B Bronze A $4,000 $4,000 $8,000 $8,000 $6,600 $13,200 $13,200 $26,400 70% 50% $60 $500 25/95/150/300 $500

MO-201501 A - 3 09/09/2014







1401C Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% $20 $20 10/30/60/150 $1001402C Gold A $1,000 $1,000 $2,000 $2,000 $4,000 $8,000 $8,000 $16,000 85% 60% $40 $40 12/40/70/175 $2001403C Gold A $600 $600 $1,200 $1,200 $4,600 $9,200 $9,200 $18,400 80% 55% 12/40/70/1751404C Silver A $1,500 $1,500 $3,000 $3,000 $5,500 $8,250 $11,000 $16,500 70% 50% 16/60/90/2251405C Silver A $2,000 $2,000 $4,000 $4,000 $5,500 $9,875 $11,000 $19,750 80% 55% 16/60/90/2251406C Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% 20/80/120/3001407C Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% 15% 15% 10/30/60/150 15%1408C Gold A $500 $500 $1,000 $1,000 $5,000 $7,500 $10,000 $15,000 70% 50% 20% 20% 12/40/70/175 20%1409C Gold A $1,000 $1,000 $2,000 $2,000 $5,500 $11,000 $11,000 $22,000 80% 55% 20% 20% 12/40/70/175 20%1410C Gold A $1,500 $1,500 $3,000 $3,000 $4,500 $8,250 $9,000 $16,500 80% 55% 20% 20% 12/40/70/175 20%1411C Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% $0 $0 16/60/90/225 $01412C Gold A $1,300 $1,300 $2,600 $2,600 $2,500 $4,500 $5,000 $9,000 85% 60% Deduct./Coins.; Specialty max $1751413C Silver A $1,750 $1,750 $3,500 $3,500 $5,000 $7,500 $10,000 $15,000 70% 50% Deduct./Coins.; Specialty max $2251414C Silver A $2,000 $2,000 $4,000 $4,000 $6,000 $11,000 $12,000 $22,000 80% 55% Deduct./Coins.; Specialty max $2251415C Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% Deduct./Coins.; Specialty max $3001416C Platinum A $0 $0 $0 $0 $1,500 $3,000 $3,000 $6,000 80% 55% $20 $20 10/30/60/150 $1501417C Gold A $1,000 $1,000 $2,000 $2,000 $3,450 $7,000 $6,900 $14,000 80% 55% $40 $40 12/40/70/175 $2001418C Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% $50 $50 16/60/90/225 $4001501C Silver A $3,000 $3,000 $6,000 $6,000 $6,600 $13,200 $13,200 $26,400 80% 60% $40 $300 16/60/90/225 $3001502C Gold A $0 $0 $0 $0 $3,200 $12,800 $6,400 $25,600 50% 50% 12/40/70/1751503C Silver A $0 $0 $0 $0 $6,600 $13,200 $13,200 $26,400 50% 50% 16/60/90/2251504C Silver A $3,000 $3,000 $6,000 $6,000 $4,500 $9,000 $9,000 $18,000 80% 60% 3free 16/60/90/2251505C Bronze A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 25/95/150/3001506C Bronze A $6,600 $6,600 $13,200 $13,200 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 20/80/120/3001507C Gold A $1,000 $1,000 $2,000 $2,000 $3,250 $6,500 $6,500 $13,000 80% 60% 20% 20% 12/40/70/175 20%1508C Gold A $2,000 $2,000 $4,000 $4,000 $3,000 $6,000 $6,000 $12,000 100% 75% 20% 20% 12/40/70/175 20%1509C Gold A $2,000 $2,000 $4,000 $4,000 $4,000 $8,000 $8,000 $16,000 80% 60% 20% 20% 12/40/70/175 20%1510C Silver A $3,500 $3,500 $7,000 $7,000 $6,250 $12,500 $12,500 $25,000 80% 60% 20% 20% 16/60/90/225 20%1511C Silver A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 80% 60% $0 $0 16/60/90/225 $01512C Silver A $2,750 $2,750 $5,500 $5,500 $3,750 $7,500 $7,500 $15,000 80% 60% Deduct./Coins.; Specialty max $2251513C Silver A $3,000 $3,000 $6,000 $6,000 $3,000 $6,000 $6,000 $12,000 100% 75% Deduct./Coins.; Specialty max $2251514C Bronze A $6,000 $6,000 $12,000 $12,000 $6,000 $12,000 $12,000 $24,000 100% 75% Deduct./Coins.; Specialty max $3001515C Bronze A $6,300 $6,300 $12,600 $12,600 $6,300 $12,600 $12,600 $25,200 100% 70% Deduct./Coins.; Specialty max $3001516C Bronze A $4,000 $4,000 $8,000 $8,000 $6,600 $13,200 $13,200 $26,400 70% 50% $60 $500 25/95/150/300 $500

MO-201501 A - 4 09/09/2014







1401D Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% $20 $20 10/30/60/150 $1001402D Gold A $1,000 $1,000 $2,000 $2,000 $4,000 $8,000 $8,000 $16,000 85% 60% $40 $40 12/40/70/175 $2001403D Gold A $600 $600 $1,200 $1,200 $4,600 $9,200 $9,200 $18,400 80% 55% 12/40/70/1751404D Silver A $1,500 $1,500 $3,000 $3,000 $5,500 $8,250 $11,000 $16,500 70% 50% 16/60/90/2251405D Silver A $2,000 $2,000 $4,000 $4,000 $5,500 $9,875 $11,000 $19,750 80% 55% 16/60/90/2251406D Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% 20/80/120/3001407D Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% 15% 15% 10/30/60/150 15%1408D Gold A $500 $500 $1,000 $1,000 $5,000 $7,500 $10,000 $15,000 70% 50% 20% 20% 12/40/70/175 20%1409D Gold A $1,000 $1,000 $2,000 $2,000 $5,500 $11,000 $11,000 $22,000 80% 55% 20% 20% 12/40/70/175 20%1410D Gold A $1,500 $1,500 $3,000 $3,000 $4,500 $8,250 $9,000 $16,500 80% 55% $0 $0 12/40/70/175 $01411D Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% $0 $0 16/60/90/225 $01412D Gold A $1,300 $1,300 $2,600 $2,600 $2,500 $4,500 $5,000 $9,000 85% 60% Deduct./Coins.; Specialty max $1751413D Silver A $1,750 $1,750 $3,500 $3,500 $5,000 $7,500 $10,000 $15,000 70% 50% Deduct./Coins.; Specialty max $2251414D Silver A $2,000 $2,000 $4,000 $4,000 $6,000 $11,000 $12,000 $22,000 80% 55% Deduct./Coins.; Specialty max $2251415D Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% Deduct./Coins.; Specialty max $3001416D Platinum A $0 $0 $0 $0 $1,500 $3,000 $3,000 $6,000 80% 55% $20 $20 10/30/60/150 $1501417D Gold A $1,000 $1,000 $2,000 $2,000 $3,450 $7,000 $6,900 $14,000 80% 55% $40 $40 12/40/70/175 $2001418D Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% $50 $50 16/60/90/225 $4001501D Silver A $3,000 $3,000 $6,000 $6,000 $6,600 $13,200 $13,200 $26,400 80% 60% $40 $300 16/60/90/225 $3001502D Gold A $0 $0 $0 $0 $3,200 $12,800 $6,400 $25,600 50% 50% 12/40/70/1751503D Silver A $0 $0 $0 $0 $6,600 $13,200 $13,200 $26,400 50% 50% 16/60/90/2251504D Silver A $3,000 $3,000 $6,000 $6,000 $4,500 $9,000 $9,000 $18,000 80% 60% 3free 16/60/90/2251505D Bronze A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 25/95/150/3001506D Bronze A $6,600 $6,600 $13,200 $13,200 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 20/80/120/3001507D Gold A $1,000 $1,000 $2,000 $2,000 $3,250 $6,500 $6,500 $13,000 80% 60% 20% 20% 12/40/70/175 20%1508D Gold A $2,000 $2,000 $4,000 $4,000 $3,000 $6,000 $6,000 $12,000 100% 75% 20% 20% 12/40/70/175 20%1509D Gold A $2,000 $2,000 $4,000 $4,000 $4,000 $8,000 $8,000 $16,000 80% 60% 20% 20% 12/40/70/175 20%1510D Silver A $3,500 $3,500 $7,000 $7,000 $6,250 $12,500 $12,500 $25,000 80% 60% $0 $0 16/60/90/225 $01511D Silver A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 80% 60% $0 $0 16/60/90/225 $01512D Silver A $2,750 $2,750 $5,500 $5,500 $3,750 $7,500 $7,500 $15,000 80% 60% Deduct./Coins.; Specialty max $2251513D Silver A $3,000 $3,000 $6,000 $6,000 $3,000 $6,000 $6,000 $12,000 100% 75% Deduct./Coins.; Specialty max $2251514D Bronze A $6,000 $6,000 $12,000 $12,000 $6,000 $12,000 $12,000 $24,000 100% 75% Deduct./Coins.; Specialty max $3001515D Bronze A $6,300 $6,300 $12,600 $12,600 $6,300 $12,600 $12,600 $25,200 100% 70% Deduct./Coins.; Specialty max $3001516D Bronze A $4,000 $4,000 $8,000 $8,000 $6,600 $13,200 $13,200 $26,400 70% 50% $60 $500 25/95/150/300 $500

MO-201501 A - 5 09/09/2014







1401E Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% $20 $20 10/30/60/150 $1001402E Gold A $1,000 $1,000 $2,000 $2,000 $4,000 $8,000 $8,000 $16,000 85% 60% $40 $40 12/40/70/175 $2001403E Gold A $600 $600 $1,200 $1,200 $4,600 $9,200 $9,200 $18,400 80% 55% 12/40/70/1751404E Silver A $1,500 $1,500 $3,000 $3,000 $5,500 $8,250 $11,000 $16,500 70% 50% 16/60/90/2251405E Silver A $2,000 $2,000 $4,000 $4,000 $5,500 $9,875 $11,000 $19,750 80% 55% 16/60/90/2251406E Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% 20/80/120/3001407E Platinum A $0 $0 $0 $0 $2,500 $5,000 $5,000 $10,000 85% 60% 15% 15% 10/30/60/150 15%1408E Gold A $500 $500 $1,000 $1,000 $5,000 $7,500 $10,000 $15,000 70% 50% 20% 20% 12/40/70/175 20%1409E Gold A $1,000 $1,000 $2,000 $2,000 $5,500 $11,000 $11,000 $22,000 80% 55% $0 $0 12/40/70/175 $01410E Gold A $1,500 $1,500 $3,000 $3,000 $4,500 $8,250 $9,000 $16,500 80% 55% $0 $0 12/40/70/175 $01411E Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% $0 $0 16/60/90/225 $01412E Gold A $1,300 $1,300 $2,600 $2,600 $2,500 $4,500 $5,000 $9,000 85% 60% Deduct./Coins.; Specialty max $1751413E Silver A $1,750 $1,750 $3,500 $3,500 $5,000 $7,500 $10,000 $15,000 70% 50% Deduct./Coins.; Specialty max $2251414E Silver A $2,000 $2,000 $4,000 $4,000 $6,000 $11,000 $12,000 $22,000 80% 55% Deduct./Coins.; Specialty max $2251415E Bronze A $5,000 $5,000 $10,000 $10,000 $6,350 $9,600 $12,700 $19,200 70% 50% Deduct./Coins.; Specialty max $3001416E Platinum A $0 $0 $0 $0 $1,500 $3,000 $3,000 $6,000 80% 55% $20 $20 10/30/60/150 $1501417E Gold A $1,000 $1,000 $2,000 $2,000 $3,450 $7,000 $6,900 $14,000 80% 55% $40 $40 12/40/70/175 $2001418E Silver A $2,000 $2,000 $4,000 $4,000 $6,350 $9,600 $12,700 $19,200 70% 50% $50 $50 16/60/90/225 $4001501E Silver A $3,000 $3,000 $6,000 $6,000 $6,600 $13,200 $13,200 $26,400 80% 60% $40 $300 16/60/90/225 $3001502E Gold A $0 $0 $0 $0 $3,200 $12,800 $6,400 $25,600 50% 50% 12/40/70/1751503E Silver A $0 $0 $0 $0 $6,600 $13,200 $13,200 $26,400 50% 50% 16/60/90/2251504E Silver A $3,000 $3,000 $6,000 $6,000 $4,500 $9,000 $9,000 $18,000 80% 60% 3free 16/60/90/2251505E Bronze A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 25/95/150/3001506E Bronze A $6,600 $6,600 $13,200 $13,200 $6,600 $13,200 $13,200 $26,400 100% 75% 3free 20/80/120/3001507E Gold A $1,000 $1,000 $2,000 $2,000 $3,250 $6,500 $6,500 $13,000 80% 60% 20% 20% 12/40/70/175 20%1508E Gold A $2,000 $2,000 $4,000 $4,000 $3,000 $6,000 $6,000 $12,000 100% 75% 20% 20% 12/40/70/175 20%1509E Gold A $2,000 $2,000 $4,000 $4,000 $4,000 $8,000 $8,000 $16,000 80% 60% $0 $0 12/40/70/175 $01510E Silver A $3,500 $3,500 $7,000 $7,000 $6,250 $12,500 $12,500 $25,000 80% 60% $0 $0 16/60/90/225 $01511E Silver A $5,000 $5,000 $10,000 $10,000 $6,600 $13,200 $13,200 $26,400 80% 60% $0 $0 16/60/90/225 $01512E Silver A $2,750 $2,750 $5,500 $5,500 $3,750 $7,500 $7,500 $15,000 80% 60% Deduct./Coins.; Specialty max $2251513E Silver A $3,000 $3,000 $6,000 $6,000 $3,000 $6,000 $6,000 $12,000 100% 75% Deduct./Coins.; Specialty max $2251514E Bronze A $6,000 $6,000 $12,000 $12,000 $6,000 $12,000 $12,000 $24,000 100% 75% Deduct./Coins.; Specialty max $3001515E Bronze A $6,300 $6,300 $12,600 $12,600 $6,300 $12,600 $12,600 $25,200 100% 70% Deduct./Coins.; Specialty max $3001516E Bronze A $4,000 $4,000 $8,000 $8,000 $6,600 $13,200 $13,200 $26,400 70% 50% $60 $500 25/95/150/300 $500

MO-201501 A - 6 09/09/2014



Attachment A - Area Definitions

Counties in Area:

1 2 3 4 5 6 7 8 9 10Andrew Adair Cass Bates Audrain Franklin Barton Barry Carter BollingerAtchison Clark Clay Benton Boone Jefferson Jasper Cedar Crawford ButlerBuchanan Knox Jackson Henry Callaway Lincoln Mc Donald Christian Dent Cape GirardeauCaldwell Lewis Platte Johnson Camden St Charles Newton Dade Howell DunklinCarroll Linn Lafayette Chariton St Francois Dallas Iron MadisonClinton Macon Pettis Cole St Louis Douglas Oregon MississippiDaviess Marion Saline Cooper St Louis City Greene Phelps New MadridDe Kalb Pike St Clair Gasconade Ste Genevieve Hickory Pulaski PemiscotGentry Putnam Vernon Howard Warren Laclede Reynolds PerryGrundy Ralls Maries Washington Lawrence Ripley ScottHarrison Schuyler Miller Ozark Shannon StoddardHolt Scotland Moniteau Polk Texas WayneLivingston Shelby Monroe StoneMercer Sullivan Montgomery TaneyNodaway Morgan WebsterRay Osage WrightWorth Randolph

MO-201501 A - 7 09/09/2014



Attachment B - Trend Impact on Index Rate

January Effective Date

April Effective Date

July Effective Date

October Effective Date

Total Single Risk Pool

Member Months 5,538 5,538 5,538 5,538 22,152

Projected Allowed Claims $389.70 $389.70 $389.70 $389.70 $389.70

Months of Trend 1.5 4.5 7.5 10.5

Annual Trend Rate 4.00% 4.00% 4.00% 4.00%

Single Risk Pool Projected Claims (=Base Allowed Claims*(1+Annual Trend)^(Months of Trend/12)) $391.62 $395.48 $399.37 $403.31 $397.45Index Rate Entered in January Template $397.45Effective Date Entered in January Template 1/1/2015

B - 1 9/9/2014MO-201501

Attachment C - Credibility Adjustment Factor

Experience based on Exposure and Claims Incurred 1/1/2013 - 12/31/2013, paid through 3/31/2014.

Step 1: Adjust State-Specific Experience for Large Claims

Missouri Allowed Charges Claim & Benefit MissouriNationwide Allowed Adjusted for Adjustment to Projected Allowed

Service Category % of Total Charges PMPM Large Claims Projection Period Trend Charges PMPM

Inpatient Hospital 22.1% 55.11 59.41 1.109 1.082 71.25Outpatient Hospital 32.2% 111.19 113.65 1.109 1.082 136.30Professional 27.2% 82.36 86.12 1.109 1.082 103.28Other Medical 2.3% 9.75 9.10 1.109 1.082 10.92Prescription Drug 16.2% 55.30 56.66 1.109 1.082 67.95

Totals 100.0% 313.71 324.95 1.109 1.082 389.70

A B C D E = B * C * D

B = Claim levels were capped at a threshold that limited the highest 5% of claims within each service category nationwide and pooled across the block based on membership.

C = Adjustments include changes in expected morbidity, additional covered benefits, and changes to network discount levels

Step 2: Determine Credibility of State-Specific Experience

Member MonthsMissouri Needed for

Service Category Member Months Full Credibility Credibility

Inpatient Hospital 73,783 855,328 29.4%Outpatient Hospital 73,783 91,830 89.6%Professional 73,783 27,327 100.0%Other Medical 73,783 508,461 38.1%Prescription Drug 73,783 25,820 100.0%

F G H = (F/G)^(1/2)

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

("An Introduction to Credibility Theory", by L.H. Longley-Cook)

Step 3: Credibility-Adjust State-Specific Experience

Missouri Manual MissouriProjected Allowed Allowed Credibilized Allowed

Service Category Charges PMPM Charges PMPM Credibility Charges PMPM

Inpatient Hospital 71.25 83.89 29.4% 80.18Outpatient Hospital 136.30 122.43 89.6% 134.86Professional 103.28 103.31 100.0% 103.28Other Medical 10.92 8.77 38.1% 9.59Prescription Drug 67.95 61.58 100.0% 67.95

Totals 389.70 379.98 395.86

E J H K = E*H + (1-H)*J

Step 4: Calculate Credibility Adjustment Factor for Claims in the Exposure Period

Combined Benefit Category Credibility Manual Weighting = (K-J)/(E-J) 1.000This is bounded such that the overall adjustment is not less than zero or greater than one based on URRT requirements.



C - 1 9/9/2014MO-201501



Attachment D - MLR Projection, Federally Prescribed

Projection Period Incurred Claims $6,969,383 [A] URRT Worksheet 1, Line 38

Projected Average Premium PMPM $8,846,853 [B] URRT Worksheet 1, Line 43Projected Premium Taxes and Fees 2.30% $203,596 [C] URRT Worksheet 1, Line 42

Projected MLR Premium $8,643,257 [D] = [B] - [C]

Projected MLR before Credibility Adjustment: 80.6% [E] = [A] / [D]

Projected Credibility Adjustment: 2.1% [F]

Projected MLR : 82.7% [G] = [E] + [F]

Projected Incurred Claims / Projected Premium (non MLR)Projected Incurred Claims $6,969,383 [A]Projected Premium $8,846,853 [B]Projected Incurred Loss Ratio 78.8% [H] = [A] / [B]

D - 1 9/9/2014MO-201501



Attachment E - Essential Health Benefits

Benefits Is this Benefit Covered?Quantitative Limit on

Service Limit Quantity Limit Unit

Primary Care Visit to Treat an Injury or Illness Covered no

Specialist Visit Covered noOther Practitioner Office Visit (Nurse, Physician

Assistant) Covered noOutpatient Facility Fee (e.g., Ambulatory Surgery

Center) Covered no

Outpatient Surgery Physician/Surgical Services Covered no

Hospice Services Covered no

Non-Emergency Care When Traveling Outside the U.S. Not Covered

Routine Dental Services (Adult) Not Covered

Infertility Treatment Not Covered

Long-Term/Custodial Nursing Home Care Not Covered

Private-Duty Nursing Covered no

Routine Eye Exam (Adult) Not Covered

Urgent Care Centers or Facilities Covered no

Home Health Care Services Covered yes 90 visits per year

Emergency Room Services Covered no

Emergency Transportation/Ambulance Covered no

Inpatient Hospital Services (e.g., Hospital Stay) Covered no

Inpatient Physician and Surgical Services Covered no

Bariatric Surgery Not Covered

MO201501 E1 07/10/2014






Cosmetic Surgery Not Covered

Skilled Nursing Facility Covered yes 90 days per year

Prenatal and Postnatal Care Covered no

Delivery and All Inpatient Services for Maternity Care Covered no

Mental/Behavioral Health Outpatient Services Covered no

Mental/Behavioral Health Inpatient Services Covered no

Substance Abuse Disorder Outpatient Services Covered no

Substance Abuse Disorder Inpatient Services Covered no

Generic Drugs Covered no

Preferred Brand Drugs Covered no

Non-Preferred Brand Drugs Covered no

Specialty Drugs Covered no

Outpatient Rehabilitation ServicesCovered yes

cardiac rehab 36 sessions; OT 20 visits, PT 20 visits; pulmonary 20 visits;

Habilitation ServicesCovered yes 20 OT 20 visits, PT 20 visits

Chiropractic CareCovered yes 26 visits per year

Durable Medical Equipment Covered no

Hearing Aids Not Covered

Imaging (CT/PET Scans, MRIs) Covered no

Preventive Care/Screening/Immunization Covered no

MO201501 E2 07/10/2014






Routine Foot Care Not Covered

Acupuncture Not Covered

Weight Loss Programs Not Covered

Routine Eye Exam for Children Covered yes 1 exam per year

Eye Glasses for Children Covered yes 1pair lenses per year and 1 frame every other year

Dental Check-Up for Children Not Covered Covered in bundled dental policy

Rehabilitative Speech Therapy Covered noRehabilitative Occupational and Rehabilitative Physical

Therapy Covered yes 20 OT 20 visits, PT 20 visits

Well Baby Visits and Care Covered no

Laboratory Outpatient and Professional Services Covered no

X-rays and Diagnostic Imaging Covered no

Basic Dental Care Child Not Covered Covered in bundled dental policy

Orthodontia Child Not Covered Covered in bundled dental policy

Major Dental Care Child Not Covered Covered in bundled dental policy

Basic Dental Care Adult Not Covered

Orthodontia Adult Not Covered

Major Dental Care Adult Not Covered

Abortion for Which Public Funding is Prohibited Not Covered

Transplant Covered no

MO201501 E3 07/10/2014






Accidental Dental Covered no

Dialysis Covered no

Allergy Testing Covered no

Chemotherapy Covered no

Radiation Covered no

Diabetes Education Covered no

Prosthetic Devices Covered no

Infusion Therapy Covered no

Treatment for Temporomandibular Joint Disorders Covered no

Nutritional Counseling Covered no

Reconstructive Surgery Covered no

Clinical Trials Covered no

Inherited Metabolic Disorder - PKU Covered no

Dental Anesthesia Covered no

Bone Marrow Testing Covered no

Applied Behavior Analysis Based Therapies Covered no

Newborn Services Other Covered no

MO201501 E4 07/10/2014

Actuarial Memorandum

Rate Filing for Federated Mutual Insurance Company

State of Missouri

Small Group Policy Form #: GH 24 10 (01-14 ed.)

Attachment F - Claims Experience Table

MO Allowed

Claims

MO Paid

Claims

Natl Allowed

Claims Natl Paid Claims

Medical Claims $18,730,923 $14,343,053 $236,224,389 $181,339,210

Pharmacy Claims $4,073,512 $3,218,846 $46,328,440 $35,771,859Incurred but Not

Reported as of

3/31/2014 $342,006 $404,767 $3,806,084 $4,840,120

Total Claim

Estimate $23,146,441 $17,966,666 $286,358,914 $221,951,189

7/14/2014MO-201501 F-1

[A][B] = Wksh 1, V35 / Wksh 1,

V33

[C] = Wksh 1, V37 / Wksh 1,

V33[D] = [A]+[B]+[C]

Plan Name HIOS Plan ID Metallic TierMember Months

Projected Index Rate Risk Adjustment

Transitional Reinsurance

Market Adjusted Index Rate

1401A 64701MO0030001 Platinum 37 $389.70 $27.28 $4.92 $421.901402A 64701MO0030002 Gold 35 $389.70 $27.28 $4.92 $421.901403A 64701MO0030003 Gold 35 $389.70 $27.28 $4.92 $421.901404A 64701MO0030004 Silver 34 $389.70 $27.28 $4.92 $421.901405A 64701MO0030005 Silver 34 $389.70 $27.28 $4.92 $421.901406A 64701MO0030006 Bronze 24 $389.70 $27.28 $4.92 $421.901407A 64701MO0030007 Platinum 37 $389.70 $27.28 $4.92 $421.901408A 64701MO0030008 Gold 35 $389.70 $27.28 $4.92 $421.901409A 64701MO0030009 Gold 35 $389.70 $27.28 $4.92 $421.901410A 64701MO0030010 Gold 35 $389.70 $27.28 $4.92 $421.901411A 64701MO0030011 Silver 34 $389.70 $27.28 $4.92 $421.901412A 64701MO0030012 Gold 35 $389.70 $27.28 $4.92 $421.901413A 64701MO0030013 Silver 34 $389.70 $27.28 $4.92 $421.901414A 64701MO0030014 Silver 34 $389.70 $27.28 $4.92 $421.901415A 64701MO0030015 Bronze 24 $389.70 $27.28 $4.92 $421.901416A 64701MO0030016 Platinum 37 $389.70 $27.28 $4.92 $421.901417A 64701MO0030017 Gold 35 $389.70 $27.28 $4.92 $421.901418A 64701MO0030018 Silver 34 $389.70 $27.28 $4.92 $421.901501A 64701MO0030091 Silver 34 $389.70 $27.28 $4.92 $421.901502A 64701MO0030092 Gold 35 $389.70 $27.28 $4.92 $421.901503A 64701MO0030093 Silver 34 $389.70 $27.28 $4.92 $421.901504A 64701MO0030094 Silver 34 $389.70 $27.28 $4.92 $421.901505A 64701MO0030095 Bronze 24 $389.70 $27.28 $4.92 $421.901506A 64701MO0030096 Bronze 24 $389.70 $27.28 $4.92 $421.901507A 64701MO0030097 Gold 35 $389.70 $27.28 $4.92 $421.901508A 64701MO0030098 Gold 35 $389.70 $27.28 $4.92 $421.901509A 64701MO0030099 Gold 35 $389.70 $27.28 $4.92 $421.901510A 64701MO0030100 Silver 34 $389.70 $27.28 $4.92 $421.901511A 64701MO0030101 Silver 34 $389.70 $27.28 $4.92 $421.901512A 64701MO0030102 Silver 34 $389.70 $27.28 $4.92 $421.901513A 64701MO0030103 Silver 34 $389.70 $27.28 $4.92 $421.90



Attachment G: Rate Development and Calibration

G-1 9/9/2014MO-201501

[A][B] = Wksh 1, V35 / Wksh 1,

V33

[C] = Wksh 1, V37 / Wksh 1,

V33[D] = [A]+[B]+[C]








1514A 64701MO0030104 Bronze 24 $389.70 $27.28 $4.92 $421.901515A 64701MO0030105 Bronze 24 $389.70 $27.28 $4.92 $421.901516A 64701MO0030106 Bronze 24 $389.70 $27.28 $4.92 $421.901401B 64701MO0030019 Platinum 37 $389.70 $27.28 $4.92 $421.901402B 64701MO0030020 Gold 35 $389.70 $27.28 $4.92 $421.901403B 64701MO0030021 Gold 35 $389.70 $27.28 $4.92 $421.901404B 64701MO0030022 Silver 34 $389.70 $27.28 $4.92 $421.901405B 64701MO0030023 Silver 34 $389.70 $27.28 $4.92 $421.901406B 64701MO0030024 Bronze 24 $389.70 $27.28 $4.92 $421.901407B 64701MO0030025 Platinum 37 $389.70 $27.28 $4.92 $421.901408B 64701MO0030026 Gold 35 $389.70 $27.28 $4.92 $421.901409B 64701MO0030027 Gold 35 $389.70 $27.28 $4.92 $421.901410B 64701MO0030028 Gold 35 $389.70 $27.28 $4.92 $421.901411B 64701MO0030029 Silver 34 $389.70 $27.28 $4.92 $421.901412B 64701MO0030030 Gold 35 $389.70 $27.28 $4.92 $421.901413B 64701MO0030031 Silver 34 $389.70 $27.28 $4.92 $421.901414B 64701MO0030032 Silver 34 $389.70 $27.28 $4.92 $421.901415B 64701MO0030033 Bronze 24 $389.70 $27.28 $4.92 $421.901416B 64701MO0030034 Platinum 37 $389.70 $27.28 $4.92 $421.901417B 64701MO0030035 Gold 35 $389.70 $27.28 $4.92 $421.901418B 64701MO0030036 Silver 34 $389.70 $27.28 $4.92 $421.901501B 64701MO0030107 Silver 34 $389.70 $27.28 $4.92 $421.901502B 64701MO0030108 Gold 35 $389.70 $27.28 $4.92 $421.901503B 64701MO0030109 Silver 34 $389.70 $27.28 $4.92 $421.901504B 64701MO0030110 Silver 34 $389.70 $27.28 $4.92 $421.901505B 64701MO0030111 Bronze 24 $389.70 $27.28 $4.92 $421.901506B 64701MO0030112 Bronze 24 $389.70 $27.28 $4.92 $421.901507B 64701MO0030113 Gold 35 $389.70 $27.28 $4.92 $421.901508B 64701MO0030114 Gold 35 $389.70 $27.28 $4.92 $421.901509B 64701MO0030115 Gold 35 $389.70 $27.28 $4.92 $421.901510B 64701MO0030116 Silver 34 $389.70 $27.28 $4.92 $421.90

G-2 9/9/2014MO-201501

[A][B] = Wksh 1, V35 / Wksh 1,

V33

[C] = Wksh 1, V37 / Wksh 1,

V33[D] = [A]+[B]+[C]








1511B 64701MO0030117 Silver 34 $389.70 $27.28 $4.92 $421.901512B 64701MO0030118 Silver 34 $389.70 $27.28 $4.92 $421.901513B 64701MO0030119 Silver 34 $389.70 $27.28 $4.92 $421.901514B 64701MO0030120 Bronze 24 $389.70 $27.28 $4.92 $421.901515B 64701MO0030121 Bronze 24 $389.70 $27.28 $4.92 $421.901516B 64701MO0030122 Bronze 24 $389.70 $27.28 $4.92 $421.901401C 64701MO0030037 Platinum 443 $389.70 $27.28 $4.92 $421.901402C 64701MO0030038 Gold 423 $389.70 $27.28 $4.92 $421.901403C 64701MO0030039 Gold 423 $389.70 $27.28 $4.92 $421.901404C 64701MO0030040 Silver 409 $389.70 $27.28 $4.92 $421.901405C 64701MO0030041 Silver 409 $389.70 $27.28 $4.92 $421.901406C 64701MO0030042 Bronze 285 $389.70 $27.28 $4.92 $421.901407C 64701MO0030043 Platinum 443 $389.70 $27.28 $4.92 $421.901408C 64701MO0030044 Gold 423 $389.70 $27.28 $4.92 $421.901409C 64701MO0030045 Gold 423 $389.70 $27.28 $4.92 $421.901410C 64701MO0030046 Gold 423 $389.70 $27.28 $4.92 $421.901411C 64701MO0030047 Silver 409 $389.70 $27.28 $4.92 $421.901412C 64701MO0030048 Gold 423 $389.70 $27.28 $4.92 $421.901413C 64701MO0030049 Silver 409 $389.70 $27.28 $4.92 $421.901414C 64701MO0030050 Silver 409 $389.70 $27.28 $4.92 $421.901415C 64701MO0030051 Bronze 285 $389.70 $27.28 $4.92 $421.901416C 64701MO0030052 Platinum 443 $389.70 $27.28 $4.92 $421.901417C 64701MO0030053 Gold 423 $389.70 $27.28 $4.92 $421.901418C 64701MO0030054 Silver 409 $389.70 $27.28 $4.92 $421.901501C 64701MO0030123 Silver 409 $389.70 $27.28 $4.92 $421.901502C 64701MO0030124 Gold 423 $389.70 $27.28 $4.92 $421.901503C 64701MO0030125 Silver 409 $389.70 $27.28 $4.92 $421.901504C 64701MO0030126 Silver 409 $389.70 $27.28 $4.92 $421.901505C 64701MO0030127 Bronze 285 $389.70 $27.28 $4.92 $421.901506C 64701MO0030128 Bronze 285 $389.70 $27.28 $4.92 $421.901507C 64701MO0030129 Gold 423 $389.70 $27.28 $4.92 $421.90

G-3 9/9/2014MO-201501

[A][B] = Wksh 1, V35 / Wksh 1,

V33

[C] = Wksh 1, V37 / Wksh 1,

V33[D] = [A]+[B]+[C]








1508C 64701MO0030130 Gold 423 $389.70 $27.28 $4.92 $421.901509C 64701MO0030131 Gold 423 $389.70 $27.28 $4.92 $421.901510C 64701MO0030132 Silver 409 $389.70 $27.28 $4.92 $421.901511C 64701MO0030133 Silver 409 $389.70 $27.28 $4.92 $421.901512C 64701MO0030134 Silver 409 $389.70 $27.28 $4.92 $421.901513C 64701MO0030135 Silver 409 $389.70 $27.28 $4.92 $421.901514C 64701MO0030136 Bronze 285 $389.70 $27.28 $4.92 $421.901515C 64701MO0030137 Bronze 285 $389.70 $27.28 $4.92 $421.901516C 64701MO0030138 Bronze 285 $389.70 $27.28 $4.92 $421.901401D 64701MO0030055 Platinum 74 $389.70 $27.28 $4.92 $421.901402D 64701MO0030056 Gold 70 $389.70 $27.28 $4.92 $421.901403D 64701MO0030057 Gold 70 $389.70 $27.28 $4.92 $421.901404D 64701MO0030058 Silver 68 $389.70 $27.28 $4.92 $421.901405D 64701MO0030059 Silver 68 $389.70 $27.28 $4.92 $421.901406D 64701MO0030060 Bronze 47 $389.70 $27.28 $4.92 $421.901407D 64701MO0030061 Platinum 74 $389.70 $27.28 $4.92 $421.901408D 64701MO0030062 Gold 70 $389.70 $27.28 $4.92 $421.901409D 64701MO0030063 Gold 70 $389.70 $27.28 $4.92 $421.901410D 64701MO0030064 Gold 70 $389.70 $27.28 $4.92 $421.901411D 64701MO0030065 Silver 68 $389.70 $27.28 $4.92 $421.901412D 64701MO0030066 Gold 70 $389.70 $27.28 $4.92 $421.901413D 64701MO0030067 Silver 68 $389.70 $27.28 $4.92 $421.901414D 64701MO0030068 Silver 68 $389.70 $27.28 $4.92 $421.901415D 64701MO0030069 Bronze 47 $389.70 $27.28 $4.92 $421.901416D 64701MO0030070 Platinum 74 $389.70 $27.28 $4.92 $421.901417D 64701MO0030071 Gold 70 $389.70 $27.28 $4.92 $421.901418D 64701MO0030072 Silver 68 $389.70 $27.28 $4.92 $421.901501D 64701MO0030139 Silver 68 $389.70 $27.28 $4.92 $421.901502D 64701MO0030140 Gold 70 $389.70 $27.28 $4.92 $421.901503D 64701MO0030141 Silver 68 $389.70 $27.28 $4.92 $421.901504D 64701MO0030142 Silver 68 $389.70 $27.28 $4.92 $421.90

G-4 9/9/2014MO-201501

[A][B] = Wksh 1, V35 / Wksh 1,

V33

[C] = Wksh 1, V37 / Wksh 1,

V33[D] = [A]+[B]+[C]








1505D 64701MO0030143 Bronze 47 $389.70 $27.28 $4.92 $421.901506D 64701MO0030144 Bronze 47 $389.70 $27.28 $4.92 $421.901507D 64701MO0030145 Gold 70 $389.70 $27.28 $4.92 $421.901508D 64701MO0030146 Gold 70 $389.70 $27.28 $4.92 $421.901509D 64701MO0030147 Gold 70 $389.70 $27.28 $4.92 $421.901510D 64701MO0030148 Silver 68 $389.70 $27.28 $4.92 $421.901511D 64701MO0030149 Silver 68 $389.70 $27.28 $4.92 $421.901512D 64701MO0030150 Silver 68 $389.70 $27.28 $4.92 $421.901513D 64701MO0030151 Silver 68 $389.70 $27.28 $4.92 $421.901514D 64701MO0030152 Bronze 47 $389.70 $27.28 $4.92 $421.901515D 64701MO0030153 Bronze 47 $389.70 $27.28 $4.92 $421.901516D 64701MO0030154 Bronze 47 $389.70 $27.28 $4.92 $421.901401E 64701MO0030073 Platinum 148 $389.70 $27.28 $4.92 $421.901402E 64701MO0030074 Gold 141 $389.70 $27.28 $4.92 $421.901403E 64701MO0030075 Gold 141 $389.70 $27.28 $4.92 $421.901404E 64701MO0030076 Silver 136 $389.70 $27.28 $4.92 $421.901405E 64701MO0030077 Silver 136 $389.70 $27.28 $4.92 $421.901406E 64701MO0030078 Bronze 95 $389.70 $27.28 $4.92 $421.901407E 64701MO0030079 Platinum 148 $389.70 $27.28 $4.92 $421.901408E 64701MO0030080 Gold 141 $389.70 $27.28 $4.92 $421.901409E 64701MO0030081 Gold 141 $389.70 $27.28 $4.92 $421.901410E 64701MO0030082 Gold 141 $389.70 $27.28 $4.92 $421.901411E 64701MO0030083 Silver 136 $389.70 $27.28 $4.92 $421.901412E 64701MO0030084 Gold 141 $389.70 $27.28 $4.92 $421.901413E 64701MO0030085 Silver 136 $389.70 $27.28 $4.92 $421.901414E 64701MO0030086 Silver 136 $389.70 $27.28 $4.92 $421.901415E 64701MO0030087 Bronze 95 $389.70 $27.28 $4.92 $421.901416E 64701MO0030088 Platinum 148 $389.70 $27.28 $4.92 $421.901417E 64701MO0030089 Gold 141 $389.70 $27.28 $4.92 $421.901418E 64701MO0030090 Silver 136 $389.70 $27.28 $4.92 $421.901501E 64701MO0030155 Silver 136 $389.70 $27.28 $4.92 $421.90

G-5 9/9/2014MO-201501

[A][B] = Wksh 1, V35 / Wksh 1,

V33

[C] = Wksh 1, V37 / Wksh 1,

V33[D] = [A]+[B]+[C]








1502E 64701MO0030156 Gold 141 $389.70 $27.28 $4.92 $421.901503E 64701MO0030157 Silver 136 $389.70 $27.28 $4.92 $421.901504E 64701MO0030158 Silver 136 $389.70 $27.28 $4.92 $421.901505E 64701MO0030159 Bronze 95 $389.70 $27.28 $4.92 $421.901506E 64701MO0030160 Bronze 95 $389.70 $27.28 $4.92 $421.901507E 64701MO0030161 Gold 141 $389.70 $27.28 $4.92 $421.901508E 64701MO0030162 Gold 141 $389.70 $27.28 $4.92 $421.901509E 64701MO0030163 Gold 141 $389.70 $27.28 $4.92 $421.901510E 64701MO0030164 Silver 136 $389.70 $27.28 $4.92 $421.901511E 64701MO0030165 Silver 136 $389.70 $27.28 $4.92 $421.901512E 64701MO0030166 Silver 136 $389.70 $27.28 $4.92 $421.901513E 64701MO0030167 Silver 136 $389.70 $27.28 $4.92 $421.901514E 64701MO0030168 Bronze 95 $389.70 $27.28 $4.92 $421.901515E 64701MO0030169 Bronze 95 $389.70 $27.28 $4.92 $421.901516E 64701MO0030170 Bronze 95 $389.70 $27.28 $4.92 $421.90

G-6 9/9/2014MO-201501

[E] [F] [G][H] = 1 / (1 -

Total Expense %)

[I] [J] [K] [L]=[E]x[F]x[G]x[H]x[I]x[J]x[K]

Plan Name HIOS Plan ID

Metallic Tier

Member Months

Cost Sharing and Actuarial

Value Adjustment

Network Adjustment

Utilization Adjustment

Expense Load

Tobacco Adjustment

Benefits in Addition to

EHBCatastrophic

Adjustment Pricing AV1401A 64701MO0030001 Platinum 37 0.886 0.973 1.000 1.269 1.000 1.005 1.000 1.0991402A 64701MO0030002 Gold 35 0.783 0.973 1.000 1.269 1.000 1.000 1.000 0.9671403A 64701MO0030003 Gold 35 0.789 0.973 1.000 1.269 1.000 0.999 1.000 0.9731404A 64701MO0030004 Silver 34 0.689 0.973 1.000 1.269 1.000 0.998 1.000 0.8491405A 64701MO0030005 Silver 34 0.685 0.973 1.000 1.269 1.000 0.992 1.000 0.8391406A 64701MO0030006 Bronze 24 0.607 0.973 1.000 1.269 1.000 1.021 1.000 0.7651407A 64701MO0030007 Platinum 37 0.891 0.973 1.000 1.269 1.000 0.999 1.000 1.0991408A 64701MO0030008 Gold 35 0.795 0.973 1.000 1.269 1.000 1.011 1.000 0.9931409A 64701MO0030009 Gold 35 0.790 0.973 1.000 1.269 1.000 1.003 1.000 0.9781410A 64701MO0030010 Gold 35 0.787 0.973 1.000 1.269 1.000 1.003 1.000 0.9751411A 64701MO0030011 Silver 34 0.717 0.973 1.000 1.269 1.000 0.972 1.000 0.8601412A 64701MO0030012 Gold 35 0.792 0.973 1.000 1.269 1.000 1.005 1.000 0.9831413A 64701MO0030013 Silver 34 0.689 0.973 1.000 1.269 1.000 1.000 1.000 0.8511414A 64701MO0030014 Silver 34 0.689 0.973 1.000 1.269 1.000 1.000 1.000 0.8511415A 64701MO0030015 Bronze 24 0.589 0.973 1.000 1.269 1.000 0.985 1.000 0.7161416A 64701MO0030016 Platinum 37 0.888 0.973 1.000 1.269 1.000 0.994 1.000 1.0901417A 64701MO0030017 Gold 35 0.781 0.973 1.000 1.269 1.000 1.009 1.000 0.9731418A 64701MO0030018 Silver 34 0.684 0.973 1.000 1.269 1.000 1.004 1.000 0.8481501A 64701MO0030091 Silver 34 0.687 0.973 1.000 1.269 1.000 0.990 1.000 0.8401502A 64701MO0030092 Gold 35 0.796 0.973 1.000 1.269 1.000 1.030 1.000 1.0121503A 64701MO0030093 Silver 34 0.710 0.973 1.000 1.269 1.000 1.003 1.000 0.8801504A 64701MO0030094 Silver 34 0.700 0.973 1.000 1.269 1.000 1.006 1.000 0.8701505A 64701MO0030095 Bronze 24 0.612 0.973 1.000 1.269 1.000 1.013 1.000 0.7651506A 64701MO0030096 Bronze 24 0.613 0.973 1.000 1.269 1.000 0.946 1.000 0.7161507A 64701MO0030097 Gold 35 0.818 0.973 1.000 1.269 1.000 1.002 1.000 1.0121508A 64701MO0030098 Gold 35 0.811 0.973 1.000 1.269 1.000 1.001 1.000 1.0021509A 64701MO0030099 Gold 35 0.787 0.973 1.000 1.269 1.000 0.996 1.000 0.9681510A 64701MO0030100 Silver 34 0.718 0.973 1.000 1.269 1.000 0.981 1.000 0.8701511A 64701MO0030101 Silver 34 0.705 0.973 1.000 1.269 1.000 0.966 1.000 0.8411512A 64701MO0030102 Silver 34 0.691 0.973 1.000 1.269 1.000 1.007 1.000 0.8591513A 64701MO0030103 Silver 34 0.717 0.973 1.000 1.269 1.000 1.004 1.000 0.889




G-7 9/9/2014MO-201501

[E] [F] [G][H] = 1 / (1 -

Total Expense %)



Metallic Tier

Member Months


Value Adjustment

Network Adjustment


Expense Load

Tobacco Adjustment


EHBCatastrophic

Adjustment Pricing AV




1514A 64701MO0030104 Bronze 24 0.592 0.973 1.000 1.269 1.000 0.980 1.000 0.7161515A 64701MO0030105 Bronze 24 0.582 0.973 1.000 1.269 1.000 0.997 1.000 0.7161516A 64701MO0030106 Bronze 24 0.616 0.973 1.000 1.269 1.000 0.988 1.000 0.7511401B 64701MO0030019 Platinum 37 0.886 1.072 1.000 1.269 1.000 1.005 1.000 1.2121402B 64701MO0030020 Gold 35 0.783 1.072 1.000 1.269 1.000 1.000 1.000 1.0661403B 64701MO0030021 Gold 35 0.789 1.072 1.000 1.269 1.000 0.999 1.000 1.0731404B 64701MO0030022 Silver 34 0.689 1.072 1.000 1.269 1.000 0.998 1.000 0.9361405B 64701MO0030023 Silver 34 0.685 1.072 1.000 1.269 1.000 0.992 1.000 0.9251406B 64701MO0030024 Bronze 24 0.607 1.072 1.000 1.269 1.000 1.021 1.000 0.8441407B 64701MO0030025 Platinum 37 0.891 1.072 1.000 1.269 1.000 0.999 1.000 1.2121408B 64701MO0030026 Gold 35 0.795 1.072 1.000 1.269 1.000 1.011 1.000 1.0941409B 64701MO0030027 Gold 35 0.790 1.072 1.000 1.269 1.000 1.003 1.000 1.0781410B 64701MO0030028 Gold 35 0.787 1.072 1.000 1.269 1.000 1.003 1.000 1.0751411B 64701MO0030029 Silver 34 0.717 1.072 1.000 1.269 1.000 0.972 1.000 0.9481412B 64701MO0030030 Gold 35 0.792 1.072 1.000 1.269 1.000 1.005 1.000 1.0841413B 64701MO0030031 Silver 34 0.689 1.072 1.000 1.269 1.000 1.000 1.000 0.9381414B 64701MO0030032 Silver 34 0.689 1.072 1.000 1.269 1.000 1.000 1.000 0.9381415B 64701MO0030033 Bronze 24 0.589 1.072 1.000 1.269 1.000 0.985 1.000 0.7891416B 64701MO0030034 Platinum 37 0.888 1.072 1.000 1.269 1.000 0.994 1.000 1.2011417B 64701MO0030035 Gold 35 0.781 1.072 1.000 1.269 1.000 1.009 1.000 1.0731418B 64701MO0030036 Silver 34 0.684 1.072 1.000 1.269 1.000 1.004 1.000 0.9351501B 64701MO0030107 Silver 34 0.687 1.072 1.000 1.269 1.000 0.990 1.000 0.9261502B 64701MO0030108 Gold 35 0.796 1.072 1.000 1.269 1.000 1.030 1.000 1.1161503B 64701MO0030109 Silver 34 0.710 1.072 1.000 1.269 1.000 1.003 1.000 0.9701504B 64701MO0030110 Silver 34 0.700 1.072 1.000 1.269 1.000 1.006 1.000 0.9591505B 64701MO0030111 Bronze 24 0.612 1.072 1.000 1.269 1.000 1.013 1.000 0.8441506B 64701MO0030112 Bronze 24 0.613 1.072 1.000 1.269 1.000 0.946 1.000 0.7891507B 64701MO0030113 Gold 35 0.818 1.072 1.000 1.269 1.000 1.002 1.000 1.1161508B 64701MO0030114 Gold 35 0.811 1.072 1.000 1.269 1.000 1.001 1.000 1.1051509B 64701MO0030115 Gold 35 0.787 1.072 1.000 1.269 1.000 0.996 1.000 1.0671510B 64701MO0030116 Silver 34 0.718 1.072 1.000 1.269 1.000 0.981 1.000 0.959

G-8 9/9/2014MO-201501

[E] [F] [G][H] = 1 / (1 -

Total Expense %)



Metallic Tier

Member Months


Value Adjustment

Network Adjustment


Expense Load

Tobacco Adjustment


EHBCatastrophic





1511B 64701MO0030117 Silver 34 0.705 1.072 1.000 1.269 1.000 0.966 1.000 0.9271512B 64701MO0030118 Silver 34 0.691 1.072 1.000 1.269 1.000 1.007 1.000 0.9471513B 64701MO0030119 Silver 34 0.717 1.072 1.000 1.269 1.000 1.004 1.000 0.9801514B 64701MO0030120 Bronze 24 0.592 1.072 1.000 1.269 1.000 0.980 1.000 0.7891515B 64701MO0030121 Bronze 24 0.582 1.072 1.000 1.269 1.000 0.997 1.000 0.7891516B 64701MO0030122 Bronze 24 0.616 1.072 1.000 1.269 1.000 0.988 1.000 0.8281401C 64701MO0030037 Platinum 443 0.886 0.998 1.000 1.269 1.000 1.005 1.000 1.1271402C 64701MO0030038 Gold 423 0.783 0.998 1.000 1.269 1.000 1.000 1.000 0.9911403C 64701MO0030039 Gold 423 0.789 0.998 1.000 1.269 1.000 0.999 1.000 0.9981404C 64701MO0030040 Silver 409 0.689 0.998 1.000 1.269 1.000 0.998 1.000 0.8711405C 64701MO0030041 Silver 409 0.685 0.998 1.000 1.269 1.000 0.992 1.000 0.8611406C 64701MO0030042 Bronze 285 0.607 0.998 1.000 1.269 1.000 1.021 1.000 0.7851407C 64701MO0030043 Platinum 443 0.891 0.998 1.000 1.269 1.000 0.999 1.000 1.1271408C 64701MO0030044 Gold 423 0.795 0.998 1.000 1.269 1.000 1.011 1.000 1.0181409C 64701MO0030045 Gold 423 0.790 0.998 1.000 1.269 1.000 1.003 1.000 1.0031410C 64701MO0030046 Gold 423 0.787 0.998 1.000 1.269 1.000 1.003 1.000 1.0001411C 64701MO0030047 Silver 409 0.717 0.998 1.000 1.269 1.000 0.972 1.000 0.8821412C 64701MO0030048 Gold 423 0.792 0.998 1.000 1.269 1.000 1.005 1.000 1.0081413C 64701MO0030049 Silver 409 0.689 0.998 1.000 1.269 1.000 1.000 1.000 0.8721414C 64701MO0030050 Silver 409 0.689 0.998 1.000 1.269 1.000 1.000 1.000 0.8731415C 64701MO0030051 Bronze 285 0.589 0.998 1.000 1.269 1.000 0.985 1.000 0.7341416C 64701MO0030052 Platinum 443 0.888 0.998 1.000 1.269 1.000 0.994 1.000 1.1181417C 64701MO0030053 Gold 423 0.781 0.998 1.000 1.269 1.000 1.009 1.000 0.9981418C 64701MO0030054 Silver 409 0.684 0.998 1.000 1.269 1.000 1.004 1.000 0.8701501C 64701MO0030123 Silver 409 0.687 0.998 1.000 1.269 1.000 0.990 1.000 0.8611502C 64701MO0030124 Gold 423 0.796 0.998 1.000 1.269 1.000 1.030 1.000 1.0381503C 64701MO0030125 Silver 409 0.710 0.998 1.000 1.269 1.000 1.003 1.000 0.9021504C 64701MO0030126 Silver 409 0.700 0.998 1.000 1.269 1.000 1.006 1.000 0.8921505C 64701MO0030127 Bronze 285 0.612 0.998 1.000 1.269 1.000 1.013 1.000 0.7851506C 64701MO0030128 Bronze 285 0.613 0.998 1.000 1.269 1.000 0.946 1.000 0.7341507C 64701MO0030129 Gold 423 0.818 0.998 1.000 1.269 1.000 1.002 1.000 1.038

G-9 9/9/2014MO-201501

[E] [F] [G][H] = 1 / (1 -

Total Expense %)



Metallic Tier

Member Months


Value Adjustment

Network Adjustment


Expense Load

Tobacco Adjustment


EHBCatastrophic





1508C 64701MO0030130 Gold 423 0.811 0.998 1.000 1.269 1.000 1.001 1.000 1.0281509C 64701MO0030131 Gold 423 0.787 0.998 1.000 1.269 1.000 0.996 1.000 0.9931510C 64701MO0030132 Silver 409 0.718 0.998 1.000 1.269 1.000 0.981 1.000 0.8921511C 64701MO0030133 Silver 409 0.705 0.998 1.000 1.269 1.000 0.966 1.000 0.8621512C 64701MO0030134 Silver 409 0.691 0.998 1.000 1.269 1.000 1.007 1.000 0.8811513C 64701MO0030135 Silver 409 0.717 0.998 1.000 1.269 1.000 1.004 1.000 0.9121514C 64701MO0030136 Bronze 285 0.592 0.998 1.000 1.269 1.000 0.980 1.000 0.7341515C 64701MO0030137 Bronze 285 0.582 0.998 1.000 1.269 1.000 0.997 1.000 0.7341516C 64701MO0030138 Bronze 285 0.616 0.998 1.000 1.269 1.000 0.988 1.000 0.7711401D 64701MO0030055 Platinum 74 0.886 0.998 1.000 1.269 1.000 1.005 1.000 1.1271402D 64701MO0030056 Gold 70 0.783 0.998 1.000 1.269 1.000 1.000 1.000 0.9911403D 64701MO0030057 Gold 70 0.789 0.998 1.000 1.269 1.000 0.999 1.000 0.9981404D 64701MO0030058 Silver 68 0.689 0.998 1.000 1.269 1.000 0.998 1.000 0.8711405D 64701MO0030059 Silver 68 0.685 0.998 1.000 1.269 1.000 0.992 1.000 0.8611406D 64701MO0030060 Bronze 47 0.607 0.998 1.000 1.269 1.000 1.021 1.000 0.7851407D 64701MO0030061 Platinum 74 0.891 0.998 1.000 1.269 1.000 0.999 1.000 1.1271408D 64701MO0030062 Gold 70 0.795 0.998 1.000 1.269 1.000 1.011 1.000 1.0181409D 64701MO0030063 Gold 70 0.790 0.998 1.000 1.269 1.000 1.003 1.000 1.0031410D 64701MO0030064 Gold 70 0.787 0.998 1.000 1.269 1.000 1.003 1.000 1.0001411D 64701MO0030065 Silver 68 0.717 0.998 1.000 1.269 1.000 0.972 1.000 0.8821412D 64701MO0030066 Gold 70 0.792 0.998 1.000 1.269 1.000 1.005 1.000 1.0081413D 64701MO0030067 Silver 68 0.689 0.998 1.000 1.269 1.000 1.000 1.000 0.8721414D 64701MO0030068 Silver 68 0.689 0.998 1.000 1.269 1.000 1.000 1.000 0.8731415D 64701MO0030069 Bronze 47 0.589 0.998 1.000 1.269 1.000 0.985 1.000 0.7341416D 64701MO0030070 Platinum 74 0.888 0.998 1.000 1.269 1.000 0.994 1.000 1.1181417D 64701MO0030071 Gold 70 0.781 0.998 1.000 1.269 1.000 1.009 1.000 0.9981418D 64701MO0030072 Silver 68 0.684 0.998 1.000 1.269 1.000 1.004 1.000 0.8701501D 64701MO0030139 Silver 68 0.687 0.998 1.000 1.269 1.000 0.990 1.000 0.8611502D 64701MO0030140 Gold 70 0.796 0.998 1.000 1.269 1.000 1.030 1.000 1.0381503D 64701MO0030141 Silver 68 0.710 0.998 1.000 1.269 1.000 1.003 1.000 0.9021504D 64701MO0030142 Silver 68 0.700 0.998 1.000 1.269 1.000 1.006 1.000 0.892

G-10 9/9/2014MO-201501

[E] [F] [G][H] = 1 / (1 -

Total Expense %)



Metallic Tier

Member Months


Value Adjustment

Network Adjustment


Expense Load

Tobacco Adjustment


EHBCatastrophic





1505D 64701MO0030143 Bronze 47 0.612 0.998 1.000 1.269 1.000 1.013 1.000 0.7851506D 64701MO0030144 Bronze 47 0.613 0.998 1.000 1.269 1.000 0.946 1.000 0.7341507D 64701MO0030145 Gold 70 0.818 0.998 1.000 1.269 1.000 1.002 1.000 1.0381508D 64701MO0030146 Gold 70 0.811 0.998 1.000 1.269 1.000 1.001 1.000 1.0281509D 64701MO0030147 Gold 70 0.787 0.998 1.000 1.269 1.000 0.996 1.000 0.9931510D 64701MO0030148 Silver 68 0.718 0.998 1.000 1.269 1.000 0.981 1.000 0.8921511D 64701MO0030149 Silver 68 0.705 0.998 1.000 1.269 1.000 0.966 1.000 0.8621512D 64701MO0030150 Silver 68 0.691 0.998 1.000 1.269 1.000 1.007 1.000 0.8811513D 64701MO0030151 Silver 68 0.717 0.998 1.000 1.269 1.000 1.004 1.000 0.9121514D 64701MO0030152 Bronze 47 0.592 0.998 1.000 1.269 1.000 0.980 1.000 0.7341515D 64701MO0030153 Bronze 47 0.582 0.998 1.000 1.269 1.000 0.997 1.000 0.7341516D 64701MO0030154 Bronze 47 0.616 0.998 1.000 1.269 1.000 0.988 1.000 0.7711401E 64701MO0030073 Platinum 148 0.886 0.998 1.000 1.269 1.000 1.005 1.000 1.1271402E 64701MO0030074 Gold 141 0.783 0.998 1.000 1.269 1.000 1.000 1.000 0.9911403E 64701MO0030075 Gold 141 0.789 0.998 1.000 1.269 1.000 0.999 1.000 0.9981404E 64701MO0030076 Silver 136 0.689 0.998 1.000 1.269 1.000 0.998 1.000 0.8711405E 64701MO0030077 Silver 136 0.685 0.998 1.000 1.269 1.000 0.992 1.000 0.8611406E 64701MO0030078 Bronze 95 0.607 0.998 1.000 1.269 1.000 1.021 1.000 0.7851407E 64701MO0030079 Platinum 148 0.891 0.998 1.000 1.269 1.000 0.999 1.000 1.1271408E 64701MO0030080 Gold 141 0.795 0.998 1.000 1.269 1.000 1.011 1.000 1.0181409E 64701MO0030081 Gold 141 0.790 0.998 1.000 1.269 1.000 1.003 1.000 1.0031410E 64701MO0030082 Gold 141 0.787 0.998 1.000 1.269 1.000 1.003 1.000 1.0001411E 64701MO0030083 Silver 136 0.717 0.998 1.000 1.269 1.000 0.972 1.000 0.8821412E 64701MO0030084 Gold 141 0.792 0.998 1.000 1.269 1.000 1.005 1.000 1.0081413E 64701MO0030085 Silver 136 0.689 0.998 1.000 1.269 1.000 1.000 1.000 0.8721414E 64701MO0030086 Silver 136 0.689 0.998 1.000 1.269 1.000 1.000 1.000 0.8731415E 64701MO0030087 Bronze 95 0.589 0.998 1.000 1.269 1.000 0.985 1.000 0.7341416E 64701MO0030088 Platinum 148 0.888 0.998 1.000 1.269 1.000 0.994 1.000 1.1181417E 64701MO0030089 Gold 141 0.781 0.998 1.000 1.269 1.000 1.009 1.000 0.9981418E 64701MO0030090 Silver 136 0.684 0.998 1.000 1.269 1.000 1.004 1.000 0.8701501E 64701MO0030155 Silver 136 0.687 0.998 1.000 1.269 1.000 0.990 1.000 0.861

G-11 9/9/2014MO-201501

[E] [F] [G][H] = 1 / (1 -

Total Expense %)



Metallic Tier

Member Months


Value Adjustment

Network Adjustment


Expense Load

Tobacco Adjustment


EHBCatastrophic





1502E 64701MO0030156 Gold 141 0.796 0.998 1.000 1.269 1.000 1.030 1.000 1.0381503E 64701MO0030157 Silver 136 0.710 0.998 1.000 1.269 1.000 1.003 1.000 0.9021504E 64701MO0030158 Silver 136 0.700 0.998 1.000 1.269 1.000 1.006 1.000 0.8921505E 64701MO0030159 Bronze 95 0.612 0.998 1.000 1.269 1.000 1.013 1.000 0.7851506E 64701MO0030160 Bronze 95 0.613 0.998 1.000 1.269 1.000 0.946 1.000 0.7341507E 64701MO0030161 Gold 141 0.818 0.998 1.000 1.269 1.000 1.002 1.000 1.0381508E 64701MO0030162 Gold 141 0.811 0.998 1.000 1.269 1.000 1.001 1.000 1.0281509E 64701MO0030163 Gold 141 0.787 0.998 1.000 1.269 1.000 0.996 1.000 0.9931510E 64701MO0030164 Silver 136 0.718 0.998 1.000 1.269 1.000 0.981 1.000 0.8921511E 64701MO0030165 Silver 136 0.705 0.998 1.000 1.269 1.000 0.966 1.000 0.8621512E 64701MO0030166 Silver 136 0.691 0.998 1.000 1.269 1.000 1.007 1.000 0.8811513E 64701MO0030167 Silver 136 0.717 0.998 1.000 1.269 1.000 1.004 1.000 0.9121514E 64701MO0030168 Bronze 95 0.592 0.998 1.000 1.269 1.000 0.980 1.000 0.7341515E 64701MO0030169 Bronze 95 0.582 0.998 1.000 1.269 1.000 0.997 1.000 0.7341516E 64701MO0030170 Bronze 95 0.616 0.998 1.000 1.269 1.000 0.988 1.000 0.771

G-12 9/9/2014MO-201501

Avg Age Fx = 1.403

[D] [L] [M]=[D]x[L] [N] [O] [P]=[M]x{N]x[O]


Metallic Tier

Member Months

Market Adjusted

Index Rate Pricing AV

Plan Adjusted

Index RateAge Factor Calibration

Geographic Calibration

Consumer Adjusted

Premium Rates1401A 64701MO0030001 Platinum 37 $421.90 1.099 $463.79 0.713 1.000 $330.641402A 64701MO0030002 Gold 35 $421.90 0.967 $407.80 0.713 1.000 $290.721403A 64701MO0030003 Gold 35 $421.90 0.973 $410.62 0.713 1.000 $292.741404A 64701MO0030004 Silver 34 $421.90 0.849 $358.19 0.713 1.000 $255.361405A 64701MO0030005 Silver 34 $421.90 0.839 $354.07 0.713 1.000 $252.421406A 64701MO0030006 Bronze 24 $421.90 0.765 $322.94 0.713 1.000 $230.221407A 64701MO0030007 Platinum 37 $421.90 1.099 $463.79 0.713 1.000 $330.641408A 64701MO0030008 Gold 35 $421.90 0.993 $418.75 0.713 1.000 $298.531409A 64701MO0030009 Gold 35 $421.90 0.978 $412.59 0.713 1.000 $294.141410A 64701MO0030010 Gold 35 $421.90 0.975 $411.25 0.713 1.000 $293.191411A 64701MO0030011 Silver 34 $421.90 0.860 $362.94 0.713 1.000 $258.741412A 64701MO0030012 Gold 35 $421.90 0.983 $414.69 0.713 1.000 $295.631413A 64701MO0030013 Silver 34 $421.90 0.851 $358.86 0.713 1.000 $255.841414A 64701MO0030014 Silver 34 $421.90 0.851 $358.95 0.713 1.000 $255.901415A 64701MO0030015 Bronze 24 $421.90 0.716 $302.10 0.713 1.000 $215.371416A 64701MO0030016 Platinum 37 $421.90 1.090 $459.73 0.713 1.000 $327.741417A 64701MO0030017 Gold 35 $421.90 0.973 $410.62 0.713 1.000 $292.741418A 64701MO0030018 Silver 34 $421.90 0.848 $357.77 0.713 1.000 $255.061501A 64701MO0030091 Silver 34 $421.90 0.840 $354.19 0.713 1.000 $252.501502A 64701MO0030092 Gold 35 $421.90 1.012 $427.11 0.713 1.000 $304.491503A 64701MO0030093 Silver 34 $421.90 0.880 $371.09 0.713 1.000 $264.561504A 64701MO0030094 Silver 34 $421.90 0.870 $366.96

Documents

2015 Federated Small Group Rate Filing.pdf