Supporting Document Schedules · 33871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 37 605.33 711.27 33871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 38 609.24 715.86

Supporting Document Schedules Satisfied - Item: ACA Public Rate Filing PDFComments:

Attachment(s): Public Rate Filing KHPE Small Group 080318 (pages 68 to 136).pdfPublic Rate Filing KHPE Small Group 080318 (pages 1 to 67).pdf

Item Status:Status Date:

SERFF Tracking #: INAC-131478481 State Tracking #: INAC-131478481 Company Tracking #: KHPE SG 1-1-2019

State: Pennsylvania Filing Company: Keystone Health Plan East, Inc.

TOI/Sub-TOI: H15G Group Health - Hospital/Surgical/Medical Expense/H15G.003 Small Group Only

Product Name: KHPE Small Group HMO eff 1-1-2019

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number INAC-131478481 Generated 10/11/2018 01:53 PM

2019 Rates Table Template v8.1 All fields with an asterisk (* ) are required. To validate press Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.

If macros are disabled, press and hold the ALT key and preIf you are in a community rating state, select Family-Tier Rates under Rating Method and fill in all columns.

If you are not in a community rating state, select Age-Based Rates under Rating Method and provide an Individual Rate for every age band.

If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use.

To add a new sheet, press the Add Sheet button, or Ctrl + Shift + H. All plans must have the same dates on a sheet.

HIOS Issuer ID* 33871Federal TIN* 23-2405376

Rate Effective Date* 1/1/2019Rate Expiration Date* 3/31/2019

Rating Method* Age-Based Rates

Plan ID* Rating Area ID* Tobacco* Age* Individual Rate* Individual Tobacco Rate*

Required:Enter the 14-character Plan ID

Required:Select the Rating Area ID

Required:Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a plan

Required:Select the age of a subscriber eligible for the

rate

Required:Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

Required:Enter the rate of an Individual tobacco

enrollee on a plan

33871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 374.05 374.0533871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 15 407.30 407.3033871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 16 420.02 420.0233871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 17 432.73 432.7333871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 18 446.42 446.4233871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 19 460.11 460.1133871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 20 474.29 474.2933871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 21 488.96 550.0833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 22 488.96 550.0833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 23 488.96 550.0833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 24 488.96 550.0833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 25 490.92 552.2833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 26 500.70 563.2833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 27 512.43 576.4833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 28 531.50 597.9433871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 29 547.15 615.5433871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 30 554.97 652.0933871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 31 566.70 665.8833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 32 578.44 679.6733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 33 585.77 688.2833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 34 593.60 697.4833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 35 597.51 702.0733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 36 601.42 706.6733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 37 605.33 711.2733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 38 609.24 715.8633871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 39 617.07 725.0533871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 40 624.89 765.4933871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 41 636.63 779.8733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 42 647.87 793.6433871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 43 663.52 812.8133871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 44 683.08 836.7733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 45 706.06 864.9233871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 46 733.44 898.4633871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 47 764.24 936.2033871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 48 799.45 979.3333871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 49 834.17 1021.8533871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 50 873.28 1200.7633871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 51 911.91 1253.8833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 52 954.45 1312.3733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 53 997.48 1371.5333871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 54 1043.93 1435.4033871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 55 1090.38 1499.2733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 56 1140.74 1568.5233871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 57 1191.60 1638.4433871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 58 1245.87 1713.0733871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 59 1272.76 1750.0533871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 60 1327.04 1824.6833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 61 1373.98 1889.2233871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 62 1404.78 1931.5833871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 63 1443.41 1984.6933871PA0100020 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1466.88 2016.9633871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 357.60 357.6033871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 15 389.39 389.3933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 16 401.55 401.5533871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 17 413.70 413.7033871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 18 426.79 426.7933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 19 439.88 439.8833871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 20 453.43 453.4333871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 21 467.46 525.8933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 22 467.46 525.8933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 23 467.46 525.8933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 24 467.46 525.8933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 25 469.33 527.9933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 26 478.68 538.5133871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 27 489.89 551.1333871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 28 508.13 571.6433871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 29 523.08 588.4733871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 30 530.56 623.4133871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 31 541.78 636.5933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 32 553.00 649.7833871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 33 560.01 658.0233871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 34 567.49 666.8033871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 35 571.23 671.2033871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 36 574.97 675.5933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 37 578.71 679.9933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 38 582.45 684.3833871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 39 589.93 693.1733871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 40 597.41 731.8333871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 41 608.63 745.5733871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 42 619.38 758.7433871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 43 634.34 777.0733871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 44 653.04 799.9733871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 45 675.01 826.8833871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 46 701.19 858.9533871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 47 730.64 895.0333871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 48 764.29 936.2633871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 49 797.48 976.9133871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 50 834.88 1147.9633871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 51 871.81 1198.7333871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 52 912.48 1254.6533871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 53 953.61 1311.22

33871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 54 998.02 1372.2833871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 55 1042.43 1433.3433871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 56 1090.58 1499.5433871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 57 1139.19 1566.3933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 58 1191.08 1637.7433871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 59 1216.79 1673.0933871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 60 1268.68 1744.4333871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 61 1313.55 1806.1433871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 62 1343.00 1846.6333871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 63 1379.93 1897.4133871PA0100021 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1402.37 1928.2633871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 292.91 292.9133871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 15 318.94 318.9433871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 16 328.90 328.9033871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 17 338.85 338.8533871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 18 349.57 349.5733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 19 360.30 360.3033871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 20 371.40 371.4033871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 21 382.89 430.7533871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 22 382.89 430.7533871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 23 382.89 430.7533871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 24 382.89 430.7533871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 25 384.42 432.4733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 26 392.07 441.0833871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 27 401.26 451.4233871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 28 416.20 468.2233871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 29 428.45 482.0133871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 30 434.58 510.6333871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 31 443.76 521.4233871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 32 452.95 532.2233871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 33 458.70 538.9733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 34 464.82 546.1733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 35 467.89 549.7733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 36 470.95 553.3733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 37 474.01 556.9633871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 38 477.08 560.5633871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 39 483.20 567.7633871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 40 489.33 599.4333871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 41 498.52 610.6833871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 42 507.32 621.4733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 43 519.58 636.4833871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 44 534.89 655.2433871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 45 552.89 677.2933871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 46 574.33 703.5533871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 47 598.45 733.1033871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 48 626.02 766.8733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 49 653.20 800.1733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 50 683.83 940.2733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 51 714.08 981.8633871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 52 747.39 1027.6733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 53 781.09 1073.9933871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 54 817.46 1124.0133871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 55 853.84 1174.0233871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 56 893.27 1228.2533871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 57 933.09 1283.0033871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 58 975.59 1341.4433871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 59 996.65 1370.4033871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 60 1039.15 1428.8333871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 61 1075.91 1479.3733871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 62 1100.03 1512.5433871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 63 1130.28 1554.1333871PA0100022 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1148.66 1579.4033871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 293.44 293.4433871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 15 319.52 319.5233871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 16 329.49 329.4933871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 17 339.47 339.4733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 18 350.21 350.2133871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 19 360.95 360.9533871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 20 372.07 372.0733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 21 383.58 431.5333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 22 383.58 431.5333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 23 383.58 431.5333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 24 383.58 431.5333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 25 385.11 433.2533871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 26 392.78 441.8833871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 27 401.99 452.2433871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 28 416.95 469.0733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 29 429.22 482.8833871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 30 435.36 511.5533871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 31 444.57 522.3733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 32 453.77 533.1833871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 33 459.53 539.9433871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 34 465.66 547.1633871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 35 468.73 550.7633871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 36 471.80 554.3733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 37 474.87 557.9733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 38 477.94 561.5833871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 39 484.08 568.7933871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 40 490.21 600.5133871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 41 499.42 611.7933871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 42 508.24 622.6033871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 43 520.52 637.6333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 44 535.86 656.4333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 45 553.89 678.5133871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 46 575.37 704.8333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 47 599.53 734.4333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 48 627.15 768.2633871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 49 654.39 801.6233871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 50 685.07 941.9733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 51 715.37 983.6433871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 52 748.75 1029.5333871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 53 782.50 1075.9433871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 54 818.94 1126.0433871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 55 855.38 1176.1533871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 56 894.89 1230.4733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 57 934.78 1285.3233871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 58 977.36 1343.8733871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 59 998.46 1372.8833871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 60 1041.03 1431.4233871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 61 1077.86 1482.0533871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 62 1102.02 1515.28

33871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 63 1132.32 1556.9533871PA0100023 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1150.74 1582.2633871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 245.18 245.1833871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 15 266.98 266.9833871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 16 275.31 275.3133871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 17 283.64 283.6433871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 18 292.62 292.6233871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 19 301.59 301.5933871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 20 310.89 310.8933871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 21 320.50 360.5733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 22 320.50 360.5733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 23 320.50 360.5733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 24 320.50 360.5733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 25 321.78 362.0133871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 26 328.19 369.2233871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 27 335.89 377.8733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 28 348.39 391.9333871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 29 358.64 403.4733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 30 363.77 427.4333871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 31 371.46 436.4733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 32 379.15 445.5133871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 33 383.96 451.1533871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 34 389.09 457.1833871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 35 391.65 460.1933871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 36 394.22 463.2133871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 37 396.78 466.2233871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 38 399.35 469.2333871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 39 404.47 475.2633871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 40 409.60 501.7633871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 41 417.29 511.1933871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 42 424.67 520.2233871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 43 434.92 532.7833871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 44 447.74 548.4833871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 45 462.81 566.9433871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 46 480.75 588.9233871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 47 500.95 613.6633871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 48 524.02 641.9333871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 49 546.78 669.8033871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 50 572.42 787.0733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 51 597.74 821.8933871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 52 625.62 860.2333871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 53 653.82 899.0133871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 54 684.27 940.8733871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 55 714.72 982.7433871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 56 747.73 1028.1333871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 57 781.06 1073.9633871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 58 816.64 1122.8833871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 59 834.27 1147.1233871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 60 869.84 1196.0333871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 61 900.61 1238.3433871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 62 920.80 1266.1033871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 63 946.12 1300.9233871PA0100024 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 961.50 1322.0733871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 242.50 242.5033871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 15 264.05 264.0533871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 16 272.30 272.3033871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 17 280.54 280.5433871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 18 289.41 289.4133871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 19 298.29 298.2933871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 20 307.48 307.4833871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 21 316.99 356.6133871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 22 316.99 356.6133871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 23 316.99 356.6133871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 24 316.99 356.6133871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 25 318.26 358.0433871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 26 324.60 365.1733871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 27 332.21 373.7333871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 28 344.57 387.6433871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 29 354.71 399.0533871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 30 359.78 422.7533871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 31 367.39 431.6933871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 32 375.00 440.6333871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 33 379.76 446.2133871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 34 384.83 452.1733871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 35 387.36 455.1533871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 36 389.90 458.1333871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 37 392.43 461.1133871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 38 394.97 464.0933871PA0100025 Rating Area 8 Tobacco User/Non-Tobacco User 39 400.04 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User/Non-Tobacco User 27 314.28 353.5633871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 28 325.97 366.7233871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 29 335.57 377.5133871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 30 340.37 399.9333871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 31 347.56 408.3933871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 32 354.76 416.8433871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 33 359.26 422.1333871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 34 364.06 427.7733871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 35 366.46 430.5833871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 36 368.85 433.4033871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 37 371.25 436.2233871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 38 373.65 439.0433871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 39 378.45 444.6833871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 40 383.25 469.4833871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 41 390.45 478.3033871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 42 397.34 486.7533871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 43 406.94 498.5033871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 44 418.93 513.1933871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 45 433.03 530.4633871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 46 449.82 551.0333871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 47 468.71 574.1833871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 48 490.31 600.6333871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 49 511.60 626.7133871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 50 535.59 736.4333871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 51 559.28 769.0133871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 52 585.37 804.8833871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 53 611.76 841.1733871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 54 640.25 880.3433871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 55 668.74 919.5133871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 56 699.62 961.9833871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 57 730.81 1004.8733871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 58 764.10 1050.6333871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 59 780.59 1073.3133871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 60 813.88 1119.0833871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 61 842.67 1158.6733871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 62 861.56 1184.6433871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 63 885.25 1217.2233871PA0100049 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 899.64 1237.01

33871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 337.39 337.3933871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 15 367.38 367.3833871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 16 378.85 378.8533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 17 390.32 390.3233871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 18 402.67 402.6733871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 19 415.01 415.0133871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 20 427.80 427.8033871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 21 441.04 496.1633871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 22 441.04 496.1633871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 23 441.04 496.1633871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 24 441.04 496.1633871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 25 442.80 498.1533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 26 451.62 508.0733871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 27 462.20 519.9833871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 28 479.41 539.3333871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 29 493.52 555.2133871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 30 500.57 588.1833871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 31 511.16 600.6133871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 32 521.74 613.0533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 33 528.36 620.8233871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 34 535.42 629.1133871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 35 538.94 633.2633871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 36 542.47 637.4133871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 37 546.00 641.5533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 38 549.53 645.7033871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 39 556.59 653.9933871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 40 563.64 690.4633871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 41 574.23 703.4333871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 42 584.37 715.8633871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 43 598.48 733.1433871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 44 616.13 754.7533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 45 636.85 780.1533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 46 661.55 810.4033871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 47 689.34 844.44

33871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 48 721.09 883.3433871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 49 752.41 921.7033871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 50 787.69 1083.0733871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 51 822.53 1130.9833871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 52 860.90 1183.7433871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 53 899.71 1237.1033871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 54 941.61 1294.7133871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 55 983.51 1352.3233871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 56 1028.94 1414.7933871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 57 1074.80 1477.8533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 58 1123.76 1545.1733871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 59 1148.01 1578.5233871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 60 1196.97 1645.8333871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 61 1239.31 1704.0533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 62 1267.09 1742.2533871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 63 1301.94 1790.1633871PA0100050 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1323.11 1819.2733871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 390.95 390.9533871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 15 425.71 425.7133871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 16 438.99 438.9933871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 17 452.28 452.2833871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 18 466.59 466.5933871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 19 480.90 480.9033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 20 495.72 495.7233871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 21 511.05 574.9333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 22 511.05 574.9333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 23 511.05 574.9333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 24 511.05 574.9333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 25 513.10 577.2333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 26 523.32 588.7333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 27 535.58 602.5333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 28 555.51 624.9533871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 29 571.87 643.3533871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 30 580.04 681.5533871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 31 592.31 695.9633871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 32 604.57 710.3733871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 33 612.24 719.3833871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 34 620.42 728.9933871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 35 624.50 733.7933871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 36 628.59 738.6033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 37 632.68 743.4033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 38 636.77 748.2033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 39 644.95 757.8133871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 40 653.12 800.0833871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 41 665.39 815.1033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 42 677.14 829.5033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 43 693.50 849.5333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 44 713.94 874.5733871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 45 737.96 904.0033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 46 766.58 939.0633871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 47 798.77 978.5033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 48 835.57 1023.5733871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 49 871.85 1068.0233871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 50 912.74 1255.0133871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 51 953.11 1310.5333871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 52 997.57 1371.6633871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 53 1042.54 1433.5033871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 54 1091.09 1500.2533871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 55 1139.64 1567.0133871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 56 1192.28 1639.3933871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 57 1245.43 1712.4733871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 58 1302.16 1790.4733871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 59 1330.27 1829.1233871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 60 1386.99 1907.1133871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 61 1436.05 1974.5733871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 62 1468.25 2018.8433871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 63 1508.62 2074.3633871PA0110011 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1533.15 2108.0933871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 373.76 373.7633871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 15 406.98 406.9833871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 16 419.69 419.6933871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 17 432.39 432.3933871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 18 446.07 446.0733871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 19 459.75 459.7533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 20 473.92 473.9233871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 21 488.57 549.6533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 22 488.57 549.6533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 23 488.57 549.6533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 24 488.57 549.6533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 25 490.53 551.8433871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 26 500.30 562.8433871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 27 512.03 576.0333871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 28 531.08 597.4733871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 29 546.71 615.0533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 30 554.53 651.5733871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 31 566.26 665.3533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 32 577.98 679.1333871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 33 585.31 687.7433871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 34 593.13 696.9333871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 35 597.04 701.5233871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 36 600.95 706.1133871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 37 604.86 710.7033871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 38 608.76 715.3033871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 39 616.58 724.4833871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 40 624.40 764.8933871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 41 636.12 779.2533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 42 647.36 793.0233871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 43 663.00 812.1733871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 44 682.54 836.1133871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 45 705.50 864.2433871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 46 732.86 897.7633871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 47 763.64 935.4633871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 48 798.82 978.5533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 49 833.51 1021.0533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 50 872.59 1199.8233871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 51 911.19 1252.8933871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 52 953.70 1311.3333871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 53 996.69 1370.4533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 54 1043.11 1434.2733871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 55 1089.52 1498.0933871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 56 1139.84 1567.29

33871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 57 1190.66 1637.1533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 58 1244.89 1711.7233871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 59 1271.76 1748.6733871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 60 1325.99 1823.2433871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 61 1372.89 1887.7333871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 62 1403.67 1930.0533871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 63 1442.27 1983.1233871PA0110012 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1465.71 2015.3733871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 305.61 305.6133871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 15 332.77 332.7733871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 16 343.16 343.1633871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 17 353.54 353.5433871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 18 364.73 364.7333871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 19 375.92 375.9233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 20 387.50 387.5033871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 21 399.49 449.4233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 22 399.49 449.4233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 23 399.49 449.4233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 24 399.49 449.4233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 25 401.08 451.2233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 26 409.07 460.2133871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 27 418.66 470.9933871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 28 434.24 488.5233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 29 447.02 502.9033871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 30 453.42 532.7633871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 31 463.00 544.0333871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 32 472.59 555.3033871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 33 478.58 562.3433871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 34 484.98 569.8533871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 35 488.17 573.6033871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 36 491.37 577.3633871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 37 494.56 581.1133871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 38 497.76 584.8733871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 39 504.15 592.3833871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 40 510.54 625.4133871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 41 520.13 637.1633871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 42 529.32 648.4233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 43 542.10 664.0833871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 44 558.08 683.6533871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 45 576.86 706.6533871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 46 599.23 734.0633871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 47 624.40 764.8933871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 48 653.16 800.1233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 49 681.52 834.8733871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 50 713.48 981.0433871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 51 745.04 1024.4333871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 52 779.80 1072.2233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 53 814.95 1120.5633871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 54 852.90 1172.7433871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 55 890.85 1224.9233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 56 932.00 1281.5033871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 57 973.55 1338.6333871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 58 1017.89 1399.6033871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 59 1039.86 1429.8133871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 60 1084.20 1490.7833871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 61 1122.55 1543.5133871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 62 1147.72 1578.1233871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 63 1179.28 1621.5133871PA0110013 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1198.46 1647.8833871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 305.53 305.5333871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 15 332.69 332.6933871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 16 343.07 343.0733871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 17 353.46 353.4633871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 18 364.64 364.6433871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 19 375.82 375.8233871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 20 387.40 387.4033871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 21 399.39 449.3133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 22 399.39 449.3133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 23 399.39 449.3133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 24 399.39 449.3133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 25 400.98 451.1133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 26 408.97 460.0933871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 27 418.56 470.8833871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 28 434.13 488.4033871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 29 446.91 502.7833871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 30 453.30 532.6333871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 31 462.89 543.8933871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 32 472.47 555.1633871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 33 478.46 562.1933871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 34 484.85 569.7033871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 35 488.05 573.4633871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 36 491.24 577.2133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 37 494.44 580.9733871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 38 497.63 584.7233871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 39 504.02 592.2333871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 40 510.41 625.2633871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 41 520.00 637.0033871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 42 529.19 648.2533871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 43 541.97 663.9133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 44 557.94 683.4833871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 45 576.71 706.4733871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 46 599.08 733.8733871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 47 624.24 764.6933871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 48 653.00 799.9233871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 49 681.35 834.6633871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 50 713.30 980.7933871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 51 744.85 1024.1733871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 52 779.60 1071.9533871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 53 814.75 1120.2833871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 54 852.69 1172.4533871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 55 890.63 1224.6233871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 56 931.77 1281.1833871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 57 973.30 1338.2933871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 58 1017.63 1399.2533871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 59 1039.60 1429.4533871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 60 1083.93 1490.4133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 61 1122.27 1543.1333871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 62 1147.43 1577.7233871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 63 1178.99 1621.1133871PA0110014 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1198.16 1647.4633871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 256.43 256.43

33871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 15 279.22 279.2233871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 16 287.94 287.9433871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 17 296.65 296.6533871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 18 306.04 306.0433871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 19 315.42 315.4233871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 20 325.14 325.1433871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 21 335.20 377.1033871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 22 335.20 377.1033871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 23 335.20 377.1033871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 24 335.20 377.1033871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 25 336.54 378.6133871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 26 343.25 386.1533871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 27 351.29 395.2033871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 28 364.36 409.9133871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 29 375.09 421.9833871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 30 380.45 447.0333871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 31 388.50 456.4833871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 32 396.54 465.9433871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 33 401.57 471.8433871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 34 406.93 478.1533871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 35 409.61 481.3033871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 36 412.30 484.4533871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 37 414.98 487.6033871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 38 417.66 490.7533871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 39 423.02 497.0533871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 40 428.39 524.7733871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 41 436.43 534.6333871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 42 444.14 544.0733871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 43 454.87 557.2133871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 44 468.27 573.6433871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 45 484.03 592.9433871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 46 502.80 615.9333871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 47 523.92 641.8033871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 48 548.05 671.3633871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 49 571.85 700.5233871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 50 598.67 823.1733871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 51 625.15 859.5833871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 52 654.31 899.6833871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 53 683.81 940.2433871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 54 715.65 984.0233871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 55 747.50 1027.8133871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 56 782.02 1075.2833871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 57 816.88 1123.2133871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 58 854.09 1174.3733871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 59 872.53 1199.7233871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 60 909.73 1250.8833871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 61 941.91 1295.1333871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 62 963.03 1324.1733871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 63 989.51 1360.5833871PA0110016 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1005.60 1382.7033871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 253.22 253.2233871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 15 275.73 275.7333871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 16 284.34 284.3433871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 17 292.94 292.9433871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 18 302.21 302.2133871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 19 311.48 311.4833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 20 321.08 321.0833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 21 331.01 372.3933871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 22 331.01 372.3933871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 23 331.01 372.3933871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 24 331.01 372.3933871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 25 332.33 373.8833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 26 338.95 381.3233871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 27 346.90 390.2633871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 28 359.81 404.7833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 29 370.40 416.7033871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 30 375.70 441.4433871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 31 383.64 450.7833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 32 391.58 460.1133871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 33 396.55 465.9533871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 34 401.85 472.1733871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 35 404.49 475.2833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 36 407.14 478.3933871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 37 409.79 481.5033871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 38 412.44 484.6233871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 39 417.73 490.8433871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 40 423.03 518.2133871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 41 430.97 527.9433871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 42 438.59 537.2733871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 43 449.18 550.2533871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 44 462.42 566.4733871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 45 477.98 585.5233871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 46 496.51 608.2333871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 47 517.37 633.7833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 48 541.20 662.9733871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 49 564.70 691.7633871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 50 591.18 812.8833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 51 617.33 848.8333871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 52 646.13 888.4333871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 53 675.26 928.4833871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 54 706.71 971.7233871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 55 738.15 1014.9633871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 56 772.25 1061.8433871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 57 806.67 1109.1733871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 58 843.41 1159.6933871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 59 861.62 1184.7333871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 60 898.36 1235.2533871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 61 930.14 1278.9433871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 62 950.99 1307.6133871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 63 977.14 1343.5733871PA0110019 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 993.03 1365.4233871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 193.29 193.2933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 15 210.47 210.4733871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 16 217.04 217.0433871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 17 223.61 223.6133871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 18 230.69 230.6933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 19 237.76 237.7633871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 20 245.09 245.0933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 21 252.67 284.2533871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 22 252.67 284.2533871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 23 252.67 284.25

33871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 24 252.67 284.2533871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 25 253.68 285.3933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 26 258.73 291.0733871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 27 264.80 297.8933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 28 274.65 308.9833871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 29 282.73 318.0833871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 30 286.78 336.9633871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 31 292.84 344.0933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 32 298.91 351.2133871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 33 302.70 355.6733871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 34 306.74 360.4233871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 35 308.76 362.7933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 36 310.78 365.1733871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 37 312.80 367.5433871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 38 314.82 369.9233871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 39 318.87 374.6733871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 40 322.91 395.5633871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 41 328.97 402.9933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 42 334.78 410.1133871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 43 342.87 420.0233871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 44 352.98 432.4033871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 45 364.85 446.9433871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 46 379.00 464.2833871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 47 394.92 483.7833871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 48 413.11 506.0633871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 49 431.05 528.0433871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 50 451.26 620.4933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 51 471.22 647.9333871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 52 493.21 678.1633871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 53 515.44 708.7333871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 54 539.44 741.7433871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 55 563.45 774.7433871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 56 589.47 810.5333871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 57 615.75 846.6633871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 58 643.80 885.2233871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 59 657.69 904.3333871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 60 685.74 942.8933871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 61 710.00 976.2433871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 62 725.91 998.1333871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 63 745.87 1025.5833871PA0110020 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 758.00 1042.25















rate




enrollee on a plan


























rate




enrollee on a plan


























rate




enrollee on a plan












No change was assumed.

The change in demographics was calculated considering changes to age, geography, and tobacco use.

The change in the average age was measured by comparing the average age factor calculated in this filing, based on February 2018 enrollments, to the average age factor calculated in the prior filing, based on February 2017 enrollments.

2018 2019Filing Filing Change

Age Factor 1.447 1.475 1.019

Change from geography: No change 1.000Change from tobacco use: No change 1.000

Total change 1.019

No changes were assumed for this filing.

The network factors used in Table 10 are based on the network differentials from the prior filing.

The network factor used for Keystone HMO was 1.100.The network factor used for Proactive was 1.000.

The factors used in Table 10 recalibrate the values so that the differntials between the factors remains constant, and the composite factor equals 1.000.

Table 10 factors: HMO 1.036Proactive 0.941

Cover Page

HIOS Issuer ID: 33871

HIOS Product ID: 33871PA010, 33871PA011

This single PDF file contains two separate actuarial certifications for the unique plan designs

under Issuer ID 33871. Please refer to all of the pages contained herein.

Unique Plan Design Supporting

Documentation and Justification ACTUARIAL MEMORANDUM


HIOS Product IDs: 33871PA010, 33871PA011

Applicable HIOS Plan IDs (Standard Component): 33871PA0100023, 33871PA0110014,

33871PA0100047, 33871PA0100024, 33871PA0110016, 33871PA0100048

Purpose of document:

The purpose of this document is to provide CMS with a justification of the methods used in

calculating the actuarial value for unique plan designs offered in the individual or small group

market for the plan year beginning 1/1/2019. As prescribed by law, the AV calculation was

based on the AV calculator to the full extent possible. The AV is meant to represent the average

percent of costs paid by the insurer for a standard population, and may vary from actual member

experience. The resulting AV was based on prescribed methodology and, therefore, may not

reasonably reflect the actuary’s estimate of the portion of allowed costs covered by the health

insurance plan. The AV was determined based on the plan’s benefits and coverage data, the

standard population, and utilization and continuance tables published by HHS for purposes of the

valuation of AV. This actuarial analysis is not appropriate for any other purposes.

Reasons the plan design is unique (benefits that are not compatible with the parameters of

the AV calculator and the materiality of those benefits):

The cost-sharing for outpatient facility fee varies by site of service. Outpatient facility fee

accounts for roughly 12% of allowed costs in the AV calculation.

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

Method 156.135(b)(2) was used for the outpatient facility site of service cost-sharing.

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

considered:

I confirm that only in-network cost-sharing was considered.

Description of the standardized plan population data used:

For the freestanding and hospital utilization data for outpatient facility, we used our commercial

PPO and HMO data incurred between August 2014 and July 2015.

If the method described in 156.135(b)(2) was used, a description of how the benefits were

modified to fit the parameters of the AV calculator:

For the outpatient facility site of service cost-sharing, our recent data indicated that 80% of

outpatient facility claims came from the hospital setting.

The cost-sharing entered into the AV calculator is a weighted average of the coinsurance at a

hospital and the coinsurance at an ambulatory surgery center.

Plans 33871PA0100023, 33871PA0110014 33871PA0100047

33871PA0100024, 33871PA0110016 33871PA0100048

Hospital Coinsurance

60% 70% 50% 70%

ASC Coinsurance

90% 100% 70% 100%

Effective Coinsurance

66.00% 76.00% 54.00% 76.00%

If the method described in 156.135(b)(3) was used, a description of the data and method

used to develop the adjustments:

Not applicable

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 the parameters 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; and

(ii) performed in accordance with generally accepted actuarial principles and methodologies.

I am an employee of the issuer, I meet the Qualification Standards for Actuaries Issuing

Statements of Actuarial Opinion in the United States promulgated by the American Academy of

Actuaries, and I have the education and experience necessary to perform this work. All AVs

herein were determined in accordance with the ASOPs established by the Actuarial Standards

Board and comply with applicable laws and regulations; furthermore, all metal levels herein

were appropriately assigned based on applicable law.

Actuary signature:

Actuary Printed Name:

Date: 5/21/2018

AV screenshots redacted.

Unique Plan Design Supporting

Documentation and Justification ACTUARIAL MEMORANDUM


HIOS Product IDs: 33871PA010, 33871PA011

Applicable HIOS Plan IDs (Standard Component): 33871PA0100026, 33871PA0110020,

33871PA0100044, 33871PA0100045

Purpose of document:

The purpose of this document is to provide CMS with a justification of the methods used in

calculating the actuarial value for unique plan designs offered in the individual or small group

market for the plan year beginning 1/1/2019. As prescribed by law, the AV calculation was

based on the AV calculator to the full extent possible. The AV is meant to represent the average

percent of costs paid by the insurer for a standard population, and may vary from actual member

experience. The resulting AV was based on prescribed methodology and, therefore, may not

reasonably reflect the actuary’s estimate of the portion of allowed costs covered by the health

insurance plan. The AV was determined based on the plan’s benefits and coverage data, the

standard population, and utilization and continuance tables published by HHS for purposes of the

valuation of AV. This actuarial analysis is not appropriate for any other purposes.

Reasons the plan design is unique (benefits that are not compatible with the parameters of

the AV calculator and the materiality of those benefits):

The cost-sharing of inpatient hospital services for these plans is a combination of copays for

facility claims and coinsurance for professional claims. Inpatient hospital services account for

about 22% of allowed costs in the AV calculation.

Plans 33871PA0100044 and 33871PA0100045 have three in-network tiers with expected third

tier utilizations of 37% and 41% respectively.

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

Method 156.135(b)(2) was used for inpatient hospital cost-sharing.

Method 156.135(b)(3) was used to accommodate the three tier design.

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

considered:

I confirm that only in-network cost-sharing was considered.

Description of the standardized plan population data used:

For the freestanding and hospital utilization data for outpatient facility, we used our commercial

PPO and HMO data incurred between August 2014 and July 2015.

If the method described in 156.135(b)(2) was used, a description of how the benefits were

modified to fit the parameters of the AV calculator:

Combination of Copays and Coinsurance for IP Hospital

The copays for inpatient hospital facility claims were combined with the coinsurance on

professional claims to calculate equivalent copays for inpatient claims.

First we took the allowed PMPY inpatient costs and divided that by the utilization by admit

PMPY to calculate the average cost per admit. We also took the utilization by day PMPY and

divided that by the utilization by admit PMPY to calculate the average length of stay.

The average cost per admit was divided by the average length of stay to calculate the average

cost per day. Based on our data, we assumed that 84% of the cost was from facility claims and

the remaining 16% was from professional claims.

The professional coinsurance was multiplied by the professional portion of the daily inpatient

cost to calculate equivalent daily copay for that piece. Because there is a 5-day maximum on our

plans’ inpatient copays, an effective copay factor was calculated by dividing the PMPY cost-

sharing from a $100 per day inpatient copay with a 5-day maximum by the PMPY cost-sharing

from a $100 per day inpatient copay without any maximum. The equivalent daily professional

copay amount was then divided by this factor in order to determine the final professional copay

reflecting a 5-day maximum.

The final professional copay was then added onto the facility copay in order to determine the

equivalent overall IP hospital copay amount. The exhibit below details this calculation.

HIOS IDs 33871PA0100026, 33871PA0110020

33871PA0100044 Tier 2

33871PA0100044 Tier 3

33871PA0100045 Tier 2

33871PA0100045 Tier 3

IP Cost Sharing

Facility $700 $700 $1,100 $900 $1,300

Professional 50% 20% 30% 5% 10%

AVC Continuance Table Bronze Gold Gold Silver Silver

PMPY for IP $1,142 $1,201 $1,201 $1,192 $1,192Admit PMPY 0.05 0.06 0.06 0.06 0.06

Claim per Admit $21,123 $20,773 $20,773 $20,989 $20,989Average LOS (days) 4.2 4.5 4.5 4.3 4.3

Effective Copay Factor for 5 days 0.50 0.46 0.46 0.49 0.49

Assumption from Data

% Facility Cost 84% 84% 84% 84% 84%

% Professional Cost 16% 16% 16% 16% 16%

Calculations

Professional Claim per Admit $3,380 $3,324 $3,324 $3,358 $3,358

Professional Claim per Day $808 $743 $743 $787 $787Equiv. Copay per Day no max $404 $149 $223 $39 $79Equiv. Copay per Day, 5-day max $813 $321 $481 $81 $161Total Copay per Day, 5-day max $1,513 $1,021 $1,581 $981 $1,461

If the method described in 156.135(b)(3) was used, a description of the data and method

used to develop the adjustments:

Using the AV calculator and the methods described above, we calculated the AV for each tier in

each plan, as follows. Based on actual tier utilization experience incurred in 2015, we projected

expected utilization by tier for the plans. The final AV for the plan was then calculated by taking

the weighted average of the tier AVs using the utilization by tier. The following exhibits details

this calculation.

Utilization Tier 1 Tier 2 Tier 3 Total

33871PA0100044 47% 16% 37% 100%

33871PA0100045 50% 9% 41% 100%

Actuarial Value

HIOS ID Tier 1 Tier 2 Tier 3 Average

33871PA0100044 78.33% 76.13% 74.77% 76.66%

33871PA0100045 75.27% 69.18% 68.49% 71.94%

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 the parameters 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; and

(ii) performed in accordance with generally accepted actuarial principles and methodologies.

I am an employee of the issuer, I meet the Qualification Standards for Actuaries Issuing

Statements of Actuarial Opinion in the United States promulgated by the American Academy of

Actuaries, and I have the education and experience necessary to perform this work. All AVs

herein were determined in accordance with the ASOPs established by the Actuarial Standards

Board and comply with applicable laws and regulations; furthermore, all metal levels herein

were appropriately assigned based on applicable law.

Actuary signature:

Actuary Printed Name:

Date: 5/21/2018

AV screenshots redacted.

REDACTION JUSTIFICATION DOCUMENT URRT Part III – Federal Actuarial Memorandum Redacted Name of opining actuary (page 8) Redacted Company Contact Information (page 1) – name, telephone number, email address PA Actuarial Memorandum Redacted Name of opining actuary (pages 6 and 7) Redacted Company Contact Information (page 1) – name, telephone number, email address Cover Letter Redacted names and contact information (page 2) AV Screenshots Entire File Redacted Unique AV Justification file Redacted name of opining actuary (pages 4 and 14) Redacted AV Screenshots (pages 5-10 and 15-22)

BlairCambria

HuntingdonWestmoreland

ClearfieldCentre

CumberlandLancaster

Lebanon

Dauphin

Schuylkill

Carbon

Cameron

York

Adams

Franklin

Juniata

Mifflin

Northumberland

Columbia

Montour

Luzerne

Lackawanna

Lehigh

DelawareFulton

Allegheny

Washington

Butler

Lawrence

Erie

Armstrong

Beaver

Bedford

Berks

Bradford

Bucks

Chester

Clarion Clinton

Crawford

Elk

Fayette

Forest

Greene

Indiana

Jefferson

Lycoming

Mckean

Mercer

Monroe

Montgomery

Northampton

Perry

Philadelphia

Pike

Potter

Snyder

Somerset

Sullivan

SusquehannaTioga

Union

Venango

Warren

Wayne

Wyoming

2018 and 2019 Service AreaIssuer: Keystone Health Plan East

Market: Small Group

Key (modify as needed)

: On-exchange service area

: Off-exchange only service area

COVER LETTER

KHPE SMALL GROUP

JUNE 14 RESPONSES

Below are responses to the questions from the June 14, 2018 objection letter. Included with this cover

letter is a workbook that contains additional requested information. Changes made to documents in

this rate filing are listed in a separate worksheet included with this letter.

In addition, the PCORI fee has been removed from the rate calculations.

1. In Wksh 2 of the URRT, the AV Pricing Values should be equal to the total adjustment from the

Market Adjusted Index Rate (MAIR) to the Plan Adjusted Index Rate (PAIR) for each plan (e.g.

MAIR x AV Pricing Value = PAIR). However, this does not appear to be the case. Please explain

why this is not the case or correct the issue to follow the Part III URRT Instructions Section 2.2.3.

We entered the AV Pricing Values from the Actuarial Memorandum Rate Exhibit. The attached

worksheet shows a calculation by plan of the product of all of the factors used in the calculation of

the plan-specific rates. Should PID prefer that those value be entered, we will revise them in the

URRT.

2. We are unable to replicate the rates on the Rate Data template using the Plan Adjusted Index

Rates (PAIRs) entered in the URRT Wksh II section IV. It appears the PAIRs entered in the URRT do

not match the Pure Premium values in column AA on tab [III Plan Rates] when removing the

aggregate calibration factor. Please explain why these values would be different. If this was done

in error, please correct the rate filing documents to be consistent.

We found that our formula for Plan Adjusted Index Rates was referencing the Age Calibration Factor

from the Actuarial Memo Rate Exhibit instead of the Aggregate Calibration Factor; the difference is

the Tobacco Calibration Factor. After this correction is made, the Plan Adjusted Index Rates in

Section IV are correct.

For example, for Plan 33871PA0100020, the value shown in the filed URRT was $721.54, which is the

First Quarter 2019 Calibrated Plan Adjusted Index Rate (Table 11, Column AC) multiplied by 1.475.

Adjusting by the Aggregate Calibration Factor provides the correct values.

3. The following questions are related to the proposed annual trend rate equal to 6.9%: a) Please

show a numerical development of the assumed annual trend rate being used to project the

experience period claims to the projected 2019 coverage year. b) Please provide the trends based

on historical allowed claims experience for each benefit category for years 2015, 2016, 2017, and

2018 (year to date). We realize 2018 trends will be partially based on estimated claim costs. c)

Please also provide a breakout of the calendar year experience between the first half and second

half of each year to demonstrate how much lower the experience observed in the first half of

2017 was than expected, as stated in the Actuarial Memorandum.

Please see below for information on the projected unit cost trends.

PA Small Group HMO Inpatient Outpatient Professional Capitation RX

2016 4.2% 3.5% 1.6% 1.8% 4.5% 2017 3.6% 2.4% 0.7% 2.5% 4.5% 2018 3.0% 2.5% 1.1% 1.4% 4.5% 2019 3.8% 3.5% 1.3% 15.0% 3.0%

Utilization 1.5% 1.5% 1.5% 0% 1.6% Composite 5.4% 5.1% 2.8% 15.0% 4.7% Weights 15% 15% 16% 22% 32%

Annual Trend 6.82%

4. The following questions are related to the Demographics factors (1.447 and 1.475) shown in the

file [ACA KHPE SG Supporting.xlsx]: a) Please show the quantitative development of the above-

referenced factors, making sure to include the membership by age that is used in calculating

them. b) Please specify what age curve is being used to determine these factors (e.g. 2019 federal

default age curve, internal age curve)?

(a) The calculation of the 2019 demographic factor is shown in the attached worksheet. This was

compared to the factor used in the 2018 rate filing to measure the change in the demographic

factor used to calculate 2019 rates.

(b) We used the 2019 federal default age curve per the PID instructions.

KHPE SG

2019 Members

Demo Factors

2019

2018 Members

Demo Factors

2018

0-20 25,041

0.812 0-20 27,622

0.811

21-29 17,166

1.037 21-29 17,909

1.032

30-39 21,052

1.207 30-39 21,633

1.202

40-49 19,035

1.461 40-49 20,429

1.457

50-59 22,336

2.193 50-59 24,156

2.182

60-63 7,725

2.831 60-63

7,346

2.825

64+ 2,507

3.000 64+

1,405

3.000

Total

114,862

1.475 Total

120,498

1.447

5. Please explain and provide the numerical development of the Change in Network Factor of 0.993

applied to the Single Risk Pool Adjustment factors entered in Table 5 of the PA Actuarial

Memorandum Exhibits.

Please see the calculation in the attached worksheet (Network Factor tab)

6. The sum of rate increase components shown in Table 8 line H does not approximate line A as

indicated by the label. Please explain why this value is so different from the change in the

Calibrated Plan Adjusted Index Rate (i.e. 4.3%).

We revised the value shown in cell C73 to be the value from the prior 2018 annual filing and line H is

much closer to line A as a result.

7. We have the following questions regarding the Benefit Richness (induced demand) column in

Table 10: a) Please provide numerical support for the Benefit Richness (induced demand) factors

shown in Table 10. b) Please confirm and demonstrate in your support that health status was not

taken into account when developing these factors. c) Please explain why these values vary so

significantly within a given metal if health status is not taken into account; for Bronze plans the

factors range from 0.815 to 0.850, for Silver plans the factors range from 0.871 to 1.034, for Gold

plans the factors range from 1.010 to 1.104, and for Platinum plans the factors range from 1.072

to 1.208.

(a) The PID-required calculation is shown in the attached worksheet.

(b) Our induced demand factors do not take into account health status.

(c) We utilized this approach because we are trying to preserve the rate relationship we currently

have in the market.

8. Please list the Non-EHB’s that are being offered and provide the numerical development of the

1.002 factor applied at the plan level shown in column M of Table 10 of the PA Actuarial

Memorandum Exhibits.

Non-EHBs are elective abortion, acupuncture, and adult vision. We estimate that the abortion and

acupuncture benefits each add 0.1% to claims. We estimate the adult vision adds 0.7% to claims but

we reflected a lower amount in pricing.

9. Please describe the methodology used to determine the provider network factor used in column N

of Table 10. Be sure to support (numerically) the underlying network factor values which are

provided in Table 14 of the PA Actuarial Memorandum Exhibits.

The provider network factor is calculated based on the expected unit cost differences between the

proactive and non-proactive networks. These differences are a combination of different contracting

between the networks. (I.e. The same facilities contracted at different rates between the two

networks) and facility mix. (I.e. Different facilities being utilized for the same services between the

two networks.)

We expect the proactive network to be 10% less expensive than the Non-proactive network. We

then normalized so that the weighted average of the factors equals 1.00.

This results in a factor of 0.941 for Proactive and 1.036 for Non-proactive. (I.e. 1.036/0.941 = 1.10 or

a 10% difference)

10. Please provide the numerical development of the tobacco surcharge of 1.011 shown in cell T6 of

Table 10.

11. Please provide the numerical development of the projected MLR calculation that shows

compliance with the 80% minimum MLR.

Projected Premium from Table 6 = $633.72

Projected Premium from Table 6 = $547.30

Projected Paid Claims from Table 5 = $382.41

Projected Risk Adjustment from Table 5= ($70.57)

QI = 0.80%; Taxes and fees = 0.52% (From table 6)

MLR = (382.41 + (547.30 x 0.008)) / (547.30 – 70.57 – (547.30 x 0.0052)) = 81.6% > 80% minimum

12. The following questions are related to the quarterly small group index rate development in Table

5A: a) Please show support and explain the methodology used to project the quarterly member

months shown in Table 5A. b) Please demonstrate quantitatively how the 2.5% quarterly trend

factor being utilized in Table 5A was developed.

(a) The distribution of members months in Table 5A is based on the February 2018 distribution by

renewal/effective date.

(b) The quarterly trend is developed within the Actuarial Memorandum Rate Exhibit using the

formulas in row 34, and considers both claims trend and the phasing out of the HIF moratorium

for premium due in calendar year 2020. The 1.025 comes from raising the annual trend to the

(1/4) power representing one-fourth of the year.

0-20 28% 5.0% -

21-29 14% 5.0% 0.125

30-39 14% 5.0% 0.175

40-49 16% 6.0% 0.225

50-59 20% 6.0% 0.375

60-63 7% 6.0% 0.375

64+ 1% 6.0% 0.375

Total

1.1%

13. We have the following questions regarding the projected risk adjustment PMPM value: a) Please

provide the quantitative development of the projected risk adjustment PMPM receipt equal to

$6.38. b) Please provide the actual 2016 risk adjustment PMPM payment/receipt.

Please see the calculation in the attached worksheet (Risk Adjustment tab).

The following additional questions or comments are from PID.

14. Please explain the discrepancy between the enrollment in Table 1, Cell D18 of 114,365 members

and Table 10, Cell AP15 of 114,861.

We revised Table 1 to include AHPA members which had been included in Table 10 but not Table 1.

The remaining difference is members who we could not associate with a HIOS ID and do not appear

in Table 10. We deemed the difference to be not material.

15. Table 2 – Please correct the Estimated Cost Sharing formula as per our telephone discussion.

We corrected the Cost Sharing formula in Table 2 as requested. This did not impact any of the

calculations later on in the Exhibit and therefore had no rate impact.

16. Rate Change Summary - The numbers in the ‘How premiums will be spent’ table add to 101%.

Please correct to add to 100%

We revised the values to total 100%. Rounding caused the filed data to add up to 101%.

17. Table 5: Please support the calculations of change in Network of 0.993

Please refer to our response to Item 5 above.

18. Table 5A: Please support the calculation of the component of 7.27% of the Annual trend in cell

J32. (the annual trend is 6.92% from Table 3 and 2.9% is for HIF).

The 7.27% trend includes a component for HIF that will be assessed for non-January first quarter

renewals. We projected that 2.9% is the annualized additional value for HIF beginning in the second

quarter. While January renewals will not be assessed the HIF over their twelve months of coverage,

February will be assessed for one month, and March for two. The filing instructions required that

we reflect the end of the moratorium either in Table 6, or as an addition to premium trend, but not

in both. We added 0.35% to the premium trend in Table 5A to account for this, which is

approximately half of one quarter of the HIF amount.

19. Table 10: Please provide the workbook with support data and calculations for the following: a)

Age calibration factor of 1.475 b) Tobacco calibration factor of 1.011 c) Benefit Richness Factors in

Column L – please provide table to support as directed on page 16 of PID Rate Filing Guidance. d)

Provider Network factors of 1.036 and 0.941 in Column N.

(a) We based the age calibration factor on the age distribution shown in the workbook attached to

this response.

(b) Please refer to Item 10 above.

(c) The table supporting Benefit Richness Factors in included in the attached workbook.

(d) The provider network factor is calculated based on the expected unit cost differences between

the Keystone and Proactive networks.

We expect the Keystone network to be 10% more expensive than the Proactive network. We


This results in a factor of 1.036 for Keystone and 0.941 for Proactive. (I.e. 1.036/0.941 = 1.10 or

a 10% difference).

20. Please confirm that you have tested to ensure that the rates in Table 11 of the Actuarial

Memorandum Exhibits, PA Plan Design Summary and Rate Tables, Federal Rates Template and the

binder are identical.

Confirmed that we made those checks prior to submitting the rate filing.

21. For the expanded Bronze plans, please demonstrate that the copay is less than or equal to 50%

coinsurance for that category.

Our average allowed cost per visit for PCP is about $120. Therefore $50 PCP copay is less than 50%

coinsurance. Specialist copay is set to 2x PCP copay.

COVER LETTER

KHPE SMALL GROUP

JULY 13 RESPONSES

1. Based on the changes noted in the file: ‘June 22 PA Revisions List.xlsx’ an updated URRT should

have been provided. However, the URRT ‘33871khpeurrtp1_sg_2019_062118_RV.xlsm’ does not

appear to include all of these changes. Please upload the June 22nd version of the URRT which we

believe should include the changes outlined.

As discussed in our previous response, we would make the revision should PID prefer that we enter

those values instead of the Pricing AV values shown in their exhibit. Nevertheless, we revised the

URRT with this response as you requested.

2. Please provide the following information related to the proposed annual trend rate equal to

6.8%:

a. Please provide a breakout of the calendar year experience between the first half and second

half of each year (i.e., for 2016, 2017, and 2018) to demonstrate how much lower the utilization

experience observed in the first half of 2017 was than expected, as stated in the Actuarial

Memorandum.

The experience is shown in Table 4 of the Actuarial Memorandum Rate Exhibit on an Incurred Basis,

and on an Allowed Claim basis in the Tab “Allowed Claims History” in the “Table For Objection KHPE

SG RV” sent with the previous response.

b. Please show the historical utilization trends for years 2016, 2017, 2018, and projected 2019

which support the 1.5% projected utilization assumption shown in row 7 of tab [Unit Cost Trends]

in the file ‘Table For Objection KHPE SG RV.xlsx’. Note: We realize 2018 trends will be partially

based on estimated claim costs.

The chart below shows the utilization used in rating for 2016, 2017, and 2018.

c. Please explain and show numerical support for the large capitation trend (15.0%) for 2019.

The capitation trend reflects increases in our payments to the providers due to contract revisions.

2016 3.42%

2017 2.94%

2018 3.21%

3. In regards to your response to the first round question 4, demographic factors, you show an

increase in projected 2019 membership for ages 64+ of 2,507 from 2018 membership of 1,405.

Please explain why you are assuming an increase in enrollment for this age bucket and provide

justification demonstrating that the assumption is appropriate.

For measurement of the change due to demography, we compare the result of the 2019 projection

to the result of the 2018 projection. The member counts shown in the “Demo Summary” compare

the projection used in the 2019 rate filing to the projection used in the 2018 filing. What was used

in the 2018 filing was the basis for the factor used then. This year’s projection is more consistent

with the membership shown in Table 1 of the Actuarial Memorandum Rate Exhibit.

4. In regards to your response to the first round question 7c) Benefit Richness factors, you state “We

utilized this approach because we are trying to preserve the rate relationship we currently have in

the market.” Please explain the “approach” you are referring to.

Consistent with last year, our induced demand factors do not take into account health status. For

2019 we did not update the induced demand factors, rather we first solved for the induced demand

factors that would generate the 2018 rates slope in 2019 before benefit changes.

We utilized this approach because we are trying to preserve the rate relationship we currently have

in the market. The approach refers to the relationship of these factors across the plans. We

maintained the same relationships used in the 2018 filing, and re-normalized them so that the

composite factor would be 1.000.

5. In regards to your response to the first round question 9 you state “We expect the proactive

network to be 10% less expensive than the Non-proactive network”. Please explain how you

determined the 10% assumption and provide any quantitative analysis that was performed in

support of this expectation.

Consistent with last year, the provider network factor is calculated based on the expected unit cost

differences between the proactive and non-proactive networks. These differences are a

combination of different contracting between the networks. (I.e. The same facilities contracted at

different rates between the two networks) and facility mix. (I.e. Different facilities being utilized for

the same services between the two networks.)

We expect the proactive network to be 10% less expensive than the Non-proactive network. We


6. In regards to your response to the first round question 13:

a. Please explain the methodology used in developing the “Risk Score PMPM” values provided in

column F of the file ‘Table For Objection KHPE SG RV.xlsx’, tab [Risk Adjustment].

This is the risk adjustment calculation.

b. Please confirm how the Membership assumptions in column C of the file ‘Table For Objection

KHPE SG RV.xlsx’, tab [Risk Adjustment] were developed.

The membership assumption was membership as of January 2018.

c. Please provide the estimated risk adjustment transfer amount PMPM for calendar year 2017. To

the extent the estimate for 2017 is significantly different than the projection for 2019, please

reconcile by describing the specific reasons for those differences and by providing justification for

any underlying changes being assumed relative to 2017 (e.g., statewide average premium, PLRS)

being assumed.

The anticipated risk adjustment payment for 2017 based on the July 9, 2018 Report for KHPE Small

Group is a payable of $26.9M. This is an approximate PMPM impact of ($18.80).

Where

PS = State average premium * 0.86; PLRSt = plan i’s plan liability risk score; AVi = plan i’s metal level

AV; ARFi = allowable rating factor; IDFi = plan i’s induced demand factor; GCFi = plan i’s geographic

cost factor;

Metal BMMO PLRS ARF GCF IDF AV

Product

w Risk

Product

w/o Risk PMPM

Plat 20,996 1.635 1.487 1.055 1.150 0.900 1.984 1.623 5.38

Gold 53,601 1.224 1.478 1.055 1.080 0.800 1.394 1.347 (70.90)

Silver 38,231 0.950 1.512 1.055 1.030 0.700 1.033 1.150 (107.76)

Bronze 2,880 0.730 1.548 1.055 1.000 0.600 0.770 0.980 (124.62)

Total 115,708 1.196 1.492 1.055 1.074 0.780 1.366 1.323

Est. StateWide Average 1.42 534.59$ 1.48 1.00 1.082 0.793 1.535 1.268

Total (70.57)

It varies from the number we are projecting for 2019, ($70.57), as for 2019, we adjusted our mix for

changes developing in 2018. We also adjusted the statewide average premium used in the

calculation.

PID’s Issues:

7. Responses for the second-round questions are due on July 13, 2018. No modifications other than

Risk adjustment updates based on Federal Risk Adjustment Report and the Department requested

changes will be accepted.

No revisions were made to these factors. However, we revised the EHB% in the URRT Part 1

Worksheet 2, Section IV, to be consistent with the Actuarial Memo Rate Exhibits.

COVER LETTER

KHPE SMALL GROUP

JULY 19 RESPONSES

1. With respect to the proposed risk adjustment transfer assumption equal to ($70.57) PMPM it is

noted in your response that this assumption is different from the actual anticipated 2017 amount

equal to ($18.80) PMPM due to adjustments which were applied to reflect changes in the

statewide average premium and changes in the mix of enrollment developing in 2018. Please

provide the following information related to these items:

a. In accounting for the changes in mix of enrollment developing in 2018, it appears that the

company is assuming that the risk transfer components (e.g., the PLRS, ARF) for each metal

level in 2019 will be equal to the values of those components for 2017 (excluding assumed

changes in the statewide average premium), but that the mix of enrollment by metal level will

be different in 2019 than that which was observed for 2017. Please confirm whether this

understanding is accurate. If it is not, please clarify.

The PLRS and ARF in the buildup are reflective of the factors as projected for 2019. They are not

the same as 2017 nor are they intended to be.

An additional notable change to account for variance between 2017 payment and projected

2019 payment is the methodology change which began in 2018; and therefore, not captured in

the 2017 results but is present in 2019.

b. The approach described in (a) appears to assume that the average risk level of the company’s

membership may be changing due to the change in the distribution of membership by metal

level. If this is not correct, please clarify and demonstrate how the shift in membership by

metal level is not reflecting a change in morbidity.

The metal mix used in buildup is from January 2018 and not an additional morbidity adjustment.

As pointed out in (a), the change in payment result between 2017 and 2019 can be attributed to

the new formula and methodology change.

c. Depending on the response to (b), the projected risk transfer amount appears to imply that

the average risk level of the company’s membership is being assumed to decrease (i.e.,

because the projected 2019 payment is greater than the anticipated payment for 2017). If the

company agrees, please revise the proposed rates accordingly to either (1) modify the current

“Change in Morbidity” assumption of 1.00 to better align with the lower average risk level

being estimated for 2019 or (2) modify the risk transfer amount in 2019 to be equal to that

anticipated for 2017, adjusted only to reflect expected changes in the statewide average

premium.

The projected risk payment change is not necessarily reflective of improvement in risk. As stated

in (a), the new formula and methodology is used beginning 2018 and therefore 2017 results are

not indicative of 2019 projections.

Completeness and Redaction Justification Checklist

SERFF ID: INAC-131478481

Redacted

(Y/N)

Page # in

Public PDF

Justification submitted

(Y/NA)

RFJ Part I - Unified Rate Review Template X

RFJ Part II – Consumer Friendly Justification X

RFJ Part III – Actuarial Memorandum X Y 60 to 67 Y

Federal Rates Template X

A.2.B. HIOS Submission X

A.2.C. SERFF Submission X

A.2.D. SERFF Rate/Rule Schedule Tab X

B. Cover Letter & PA Bulletin Information X

C. Rate Change Request Summary X

D.1.A. Company Information X Y 9 Y

D.1.B. Rate History & Proposed Variation in Rate Changes X N 10 N/A

D.1.C. Average Rate Change X N 10 N/A

Membership Count X N 10 N/A

PA Act. Exhibits Table 1 X N 16 N/A

D.1.E. Benefit Changes X N 10 N/A

Experience Period Claims & Premium X N 10 to 11 N/A


Credibility of Data X N 11 N/A

PA Act. Exhibits Tables 2b, 3b, 4b (if applicable) N/A N N/A N/A

Trend Identification X N 11 to 12 N/A


Historical Experience X N 12 N/A


Development of PAIR, MAIR and Total Allowed Claims X N 12 to 13 N/A


Retention Items X N 13 N/A


Normalized Market-Adjusted Projected Allowed Total Claims X N 13 N/A


Components of Rate Change X N 14 N/A



Plan Rate Development X N 14 N/A


Plan Premium Development for 21-Year-Old Non-Tobacco User X N 14 N/A

PA Act. Exhibits Table 11 X N 20 to 23 N/A

Age and Tobacco Factors X N 14 N/A


Geographic Factors X N 14 N/A


Network Factors X N 14 N/A


D.5.D. Service Area Composition N/A N N/A N/A

D.5.E. Composite Rating N/A N N/A N/A

D.6. Actuarial Certifications X Y 14 to 15 Y

Department Plan Design Summary & Rate Tables X N 25 to 52 N/A

Service Area Map X N 123 N/A

X YRedaction Justification (must be submitted if any information is redacted)

PA Actuarial Memorandum and Rate Exhibits

Federal Documents Required to Be Filed with PID

Summary Documents/Confirmation of HIOS & SERFF Submissions

Additional Exhibits

D.1.D.

D.5.B.

D.5.C.

A.2.

E.

D.2.C.

D.2.D.

D.3.

D.4.

D.5.A.

D.1.G.

Issuer Name: Keystone Health Plan East

Market: Small Group HMO

Redaction JustificationCompleted

(Mark with "X")TOC # Description

D.1.H.

D.1.I.

D.2.A.

D.2.B.

D.1.F.

May 21, 2018

Ms. Tracie Gray, Director

Bureau of Accident and Health Insurance

Pennsylvania Insurance Department

1311 Strawberry Square

Harrisburg, PA 17120

SUBMITTED VIA SERFF

RE: Keystone Health Plan East

Small Group HMO Rate Filing effective 1/1/2019

INAC-131478481

Dear Ms. Gray:

Attached is the rating methodology for HMO plans of Keystone Health Plan East

(KHPE), and Direct Point-of-Service (DPOS) plans, of which a large majority of benefit

expenses is attributed to KHPE and the remainder to QCC Insurance Company (QCC),

and offered to small employer groups in the Commonwealth of Pennsylvania. Rates for

new and renewing plans are being filed and satisfy market reform requirements of the

Affordable Care Act (ACA).

This rate filing includes rates for these plans and specifies compliance with rating

requirements of the ACA. The enclosed is for rating periods effective from January 1,

2019 through December 31, 2019.

The proposed rates represent a 4.3% increase over the previously approved 2018 rates.

Information for the Pennsylvania Bulletin:

1. Company Name and NAIC Number: Keystone Health Plan East; 95056

2. Market Small Group

3. On or Off Exchange Off

4. Effective Date of Coverage January 1, 2019

5. Average Rate Change Requested 4.3%

6. Range of Rate Changes Requested 0.7% - 5.4%

7. Total Annual Revenue Generated from

the Proposed Rate Change $30,201,456

8. Products HMO

9. Rating Areas and Change from 2018 Rating Area 8; No Change

10. Metal Levels and Catastrophic Plans Platinum, Gold, Silver, Bronze

11. Current covered lives and policyholders 114,365 lives

as of February 1, 2018 16,061 policyholders

12. Number of plans offered in 2019 and 20 plans in 2019; 20 plans in 2018

change from 2018

13. Corresponding contract form number, SERFF # INBC-131478601

SERFF, and binder numbers See appendix for form numbers.

14. HIOS Issuer ID # and submission tracking HIOS Issuer ID # 33871; Filing #

Number 33871-1224466136146424836

Please contact XXXXXXXXXXXX at XXXXXXXXXXXX or XXXXXXXXXXXX with any

questions regarding this filing

Sincerely,

XXXXXXXXXXXX

Director and Actuary, Commercial Pricing

cc: XXXXXXXXXXXX

XXXXXXXXXXXX

APPENDIX

Form Numbers

KE 670 WPR GMC Rev. 1.19, KE 670 SG EXC-OFF Rev. 1.19, KE 670 SG EXC-OFF.Tier

Rev. 1.19, KE 670 SG EXC-OFF.Direct Rev. 1.19, KE 670 SG EXC-OFF.Direct.ADental Rev.

1.19, 16905.WR.KDPOS Rev. 1.19, 16905-BC.SG.KDPOS.OFF.ADEN Rev. 1.19, 16905-

BC.SG.KDPOS.OFF Rev. 1.19, PREV/SCH-II Rev. 1.19

Rate Change Summary

Keystone Health Plan East – Small Group Plans

Rate request filing ID INAC-131478481 - This document is prepared by the insurance company submitting the rate filing as a consumer tool to help explain the rate filing. It is not intended to describe or include all factors or information considered in the review process. For more information, see the filing at http://www.insurance.pa.gov/Consumers/ACARelatedFilings/

Overview Initial requested average rate change: 4.3%1 Revised requested average rate change: N/A1 Range of requested rate change: 0.6% - 5.3% Effective date: January 1, 2019 People impacted: 114,365 Available in: Area 8

Key information

Jan. 2017-Dec. 2017 financial experience

Premiums $646,128,766

Claims $451,358,874

Administrative expenses $115,719,582

Taxes & fees $24,917,439

Company made (after taxes) $54,132,871

The company expects its annual medical costs to increase 6.9%.

Explanation of requested rate change

Scope and Range of the Rate Increase: Keystone Health Plan East ("KHPE”) is revising premium rates for the Pennsylvania Small Group ACA compliant products, effective from January 1, 2019. About 114,000 members will be affected. Financial Experience of the Product: KHPE is required by federal law to pay out a minimum of 80% percent of premium dollars for medical

1 Note that insurers will have the opportunity to revise their rate change request in July, after they are scheduled to receive updated information about the impact of a federal program called risk adjustment. This document will be updated accordingly at that time.

How it plans to spend your premium This is how the insurance company plans to spend the premium it collects in 2019:

Claims: 83% Administrative: 14.5% Taxes & fees: 0.5% Profit: 2%

http://www.insurance.pa.gov/Consumers/ACARelatedFilings

claims—this is referred to as the minimum Medical Loss Ratio (MLR). The rate action proposed in this filing is expected to achieve a Medical Loss Ratio of greater than 80%. Changes in Medical Service Costs: Premium rates for health care insurance are increasing as the cost of health care service rise. Health care service costs increase as health care providers increase their fees, members use more health care services and supplies, and the types of health care services and supplies change, among other factors. We are projecting that claims will increase by 6.9% in 2019. Nearly half of the change in health care service costs is driven by changes to health care provider fees. Changes in Benefits: Some plan benefits are mandated by federal and state law. Benefit changes for some plans were also made. All changes in benefits are in compliance with the uniform modifications rules stipulated by the Federal government. Administrative Costs: In addition, the Affordable Care Act (ACA) imposes taxes and other levies.

July 13, 2018

Ms. Tracie Gray, Director

Bureau of Accident and Health Insurance

Pennsylvania Insurance Department

1311 Strawberry Square

Harrisburg, PA 17120

SUBMITTED VIA SERFF

RE: Keystone Health Plan East

Small Group HMO Rate Filing effective 1/1/2019 - REVISED

INAC-131478481

Dear Ms. Gray:

Attached is the rating methodology for HMO plans of Keystone Health Plan East

(KHPE), and Direct Point-of-Service (DPOS) plans, of which a large majority of benefit

expenses is attributed to KHPE and the remainder to QCC Insurance Company (QCC),

and offered to small employer groups in the Commonwealth of Pennsylvania. Rates for

new and renewing plans are being filed and satisfy market reform requirements of the

Affordable Care Act (ACA).

This rate filing includes rates for these plans and specifies compliance with rating

requirements of the ACA. The enclosed is for rating periods effective from January 1,

2019 through December 31, 2019.

The proposed rates represent a 4.3% increase over the previously approved 2018 rates.

Information for the Pennsylvania Bulletin:

1. Company Name and NAIC Number: Keystone Health Plan East; 95056

2. Market Small Group

3. On or Off Exchange Off

4. Effective Date of Coverage January 1, 2019

5. Average Rate Change Requested 4.3%

6. Range of Rate Changes Requested 0.6% - 5.3%

7. Total Annual Revenue Generated from

the Proposed Rate Change $29,849,007

8. Products HMO

9. Rating Areas and Change from 2018 Rating Area 8; No Change

10. Metal Levels and Catastrophic Plans Platinum, Gold, Silver, Bronze

11. Current covered lives and policyholders 114,365 lives

as of February 1, 2018 16,061 policyholders

12. Number of plans offered in 2019 and 20 plans in 2019; 20 plans in 2018

change from 2018

13. Corresponding contract form number, SERFF # INBC-131478601

SERFF, and binder numbers See appendix for form numbers.

14. HIOS Issuer ID # and submission tracking HIOS Issuer ID # 33871; Filing #

Number 33871-1224466136146424836

Please contact XXXXXXXXXX at XXXXXXXXXX or XXXXXXXXXX with any

questions regarding this filing.

Sincerely,

XXXXXXXXXXXXXXXXXXXX

Director and Actuary, Commercial Pricing

cc: XXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXX

APPENDIX

Form Numbers

KE 670 WPR GMC Rev. 1.19, KE 670 SG EXC-OFF Rev. 1.19, KE 670 SG EXC-OFF.Tier

Rev. 1.19, KE 670 SG EXC-OFF.Direct Rev. 1.19, KE 670 SG EXC-OFF.Direct.ADental Rev.

1.19, 16905.WR.KDPOS Rev. 1.19, 16905-BC.SG.KDPOS.OFF.ADEN Rev. 1.19, 16905-

BC.SG.KDPOS.OFF Rev. 1.19, PREV/SCH-II Rev. 1.19

INAC-131478481 1 PA Actuarial Memorandum KHPE Small Group May 21, 2018

PENNSYLVANIA ACTUARIAL MEMORANDUM

PURPOSES

This Actuarial Memorandum is provided along with the Unified Rate Review Template (URRT) and PA

Actuarial Memorandum Rate Exhibits to provide certain information to support the gross premium for

the single risk pool for small group market health care insurance underwritten by Keystone Health Plan

East in the Commonwealth of Pennsylvania. It is provided as a component of a state rate filing. This

submission may not be appropriate for other purposes.

1. BASIC INFORMATION AND DATA

A. COMPANY INFORMATION

Company Legal Name: Keystone Health Plan East (“KHPE”)

State: Pennsylvania

NAIC #: 95056

Market: Small Group

Marketplace: Off Exchange

Effective Date(s): 1/1/2019-3/31/2019, 4/1/2019 – 6/30/2019, 7/1/2019 – 9/30/2019,

10/1/2019 – 12/31/2019

Average Rate Change: 4.3%

Range of Rate Changes: 0.6% - 5.3%

Products: HMO

Rating Areas: Rating Area 8

Metal Levels: Platinum, Gold, Silver, Bronze

Current Members: 114,365

Current Policyholders: 16,061

Number of 2019 Plans: 20

HIOS Issuer ID (5-digit): 33871

Worksheet 1 of the accompanying URRT contains experience period data and development of the

projected Single Risk Pool Gross Premium Average Rate PMPM for the small group market for KHPE.

Worksheet 2 contains experience period data and projections by product for the single risk pool for the

same entities. This memorandum pertains only to plans denoted in Worksheet 2 by Plan IDs starting

with the sequence 33871.

COMPANY CONTACT INFORMATION

Primary Contact Name: XXXXXXXXXXXX

Primary Contact Telephone Number: XXXXXXXXXXXX

Primary Contact Email Address: XXXXXXXXXXXX XXXXXXXXXXXX


B. RATE HISTORY AND PROPOSED VARIATIONS IN RATE CHANGES

January 1, 2015 8.40% INAC- 129626509

October 1, 2015 -0.30% INAC- 130111004

January 1, 2016 6.88% INAC- 129955625

January 1, 2017 27.97% INAC- 130539718

July 1, 2017 2.00% INAC- 130959307

January 1, 2018 10.19% INAC- 131005809

July 1, 2018 1.59% INAC- 131405465

The historical rate changes varied by metallic tier based on plan benefits as illustrated via the Pricing AV.

Proposed rate changes may vary by metallic tier and plan based on plan benefit changes.

C. AVERAGE RATE CHANGE

The average proposed rate change shown in Cell AC15 of Table 10 is 4.3%. The changes to the single risk

pool gross premium average rate per member per month (PMPM) from calendar year 2017 to calendar

year 2019 are incorporated into the pricing and reflected in the Unified Rate Review Template.

The change in 21-year-old Non-Tobacco Premium PMPM calculated in Table 11, Cell AN13 is 0.7%.

The change shown in Cell V45 of Worksheet 1 of URRT Part I is 8.61%. The change shown in Cell V46 of

Worksheet 1 of URRT Part I is 4.22%.

D. MEMBERSHIP COUNT

Table 1 illustrates the Experience Period member-months, Current Period members as of February 1,

2018, and Projected Rating Period Member-months by ages.

E. BENEFIT CHANGES

Benefit changes were made to the following plans to assure compliance with Actuarial Value

Requirements, including differences that resulted from changes to the AV Calculator. The basis for

pricing changes was our internal pricing model.

F. EXPERIENCE PERIOD CLAIMS AND PREMIUMS

Table 2 illustrates the experience period claims and premiums using calendar year data. The data is

consistent with the data reported in Section 1 of Worksheet I of the URRT.


Experience period premium, claims, and member months are obtained from the company’s internal

data warehouse. The claims data is collected for incurred dates from January through December 2017

and paid through February 2018. Earned premiums and member months are for January through

December 2017. The data are for all direct-written small group business of KHPE in the Commonwealth

of Pennsylvania, including out-of-network claims written by KHPE but paid by QCC for POS plans. No

private reinsurance was applicable.

Projected Risk Adjustment PMPM

Non-EHB benefits are illustrated separately in cell H36 of Table 2. Capitation is uniform by age for the

experience period. Net pharmacy rebates are illustrated in cell I36 of Table 2.

Projected Risk Adjustment is accounted for in Projected Incurred Claims before ACA Reinsurance and

Risk Adjustment to reflect anticipated risk adjustment transfer amounts for the projection period. The

amount reflects the projected morbidity for the single risk pool for IBCFOC in the projection period.

The estimated risk adjustment revenue for all of the plans in the risk pool is developed using the

following methodology. We recognize that the HHS payment transfer formula implies that the projected

incurred claims based solely on the experience period single risk pool claims need to be adjusted by the

ratio of the current statewide market’s risk relative to allowable rating factor (ARF) for age compared to

the single risk pool’s risk relative to ARF presented during the experience period. This adjustment,

together with the assumed future changes in population risk morbidity, results in the issuer’s pricing

being consistent with the anticipated morbidity level of the future statewide market.

The anticipated risk adjustment transfer revenue is allocated proportionally based on plan premium.

The Projected Risk Adjustment is subtracted from Projected Incurred Claims before ACA Risk Adjustment

to reflect anticipated receipt of risk adjustment transfer amounts for the projection period.

When the projected risk adjustment amounts for KHPE and Independence Blue Cross (QCC) are

combined, the result is consistent with the projection made in our submission. We also considered

preliminary 2017 risk transfer results.

G. CREDIBILITY OF DATA

The experience period data is considered 100% credible.

H. TREND IDENTIFICATION

Table 3 identifies the proposed annual medical and prescription drug allowed claims cost and utilization

trends. These data match the data illustrated in Section 2 of Worksheet I of the URRT. Additional

discussion is provided in Section I, Historical Experience.


We observed significantly lower than expected experience in the first half of 2017. We have updated

our trends to reflect that the low first half utilization will not repeat in 2018 and 2019. Specifically, we

expect the first half of 2019 to be similar to what we are seeing in the first half of 2018.

I. HISTORICAL EXPERIENCE

Table 4 illustrates historical experience from 2014 through 2017 for the product line.

a. Annualized Cost Trend

Annual cost trend reflects changes in costs of medical treatment due to medical inflation and changes in

the distribution of services across network providers. The trend value is developed by reviewing

historical medical costs for the single risk pool and adjusting them for anticipated future provider

contracting reimbursement levels. The data is normalized for changes in age, benefit changes during the

experience period, changes to provider contracts, and prescription drug formulary, and new drugs

brought to market.

b. Annualized Utilization Trend

Annual utilization trend reflects the change in the number of units per 1,000 members for a fixed level

of illness burden and includes changes due to the mix and intensity of services provided and changes

related to shifts in product mix. It also includes effects of selection, if any, since this cannot be reflected

in the relative cost of the various products and plans offered.

J. TERMINATED PLANS

No plans are being terminated during 2019.

2. RATE DEVELOPMENT AND CHANGE

A. DEVELOPMENT OF PROJECTED INDEX RATE, MARKET-ADJUSTED INDEX RATE, & TOTAL

ALLOWED CLAIMS

Table 5 illustrates the development of the Projected Index Rate and Market-Adjusted Index Rate

beginning with the Experience Period Index Rate. Exhibit A provides additional information about the

adjustment factors.

Changes in Population Risk Morbidity

Experience period allowed claims are adjusted to account for differences in the average morbidity of the

single risk pool population underlying the experience and the anticipated population in the projection

period. This adjustment reflects changes in the small group market-wide morbidity.

Changes in Other Factors


Experience period allowed claims are adjusted to account for differences in the single risk pool

population underlying the experience and the anticipated population in the projection period pertaining

to several factors not due to changes in morbidity or the costs and utilization of medical care. This

adjustment reflects: additional benefits required to be covered as essential health benefits; recently

mandated benefits required by state law that are not reflected in the experience period data; benefits in

the experience that are removed for the projection period; anticipated changes in the average

utilization of services due to differences in average cost sharing requirements during the experience

period and average cost sharing requirements in the projection period; changes in demographic

characteristics of the single risk pool experience period population and the projection period population

(including age, gender, region, and tobacco use); changes in the provider network (adding or removing a

provider system or introducing a limited network option); and anticipated changes in pharmacy rebates.

Table 5 of the Actuarial Memorandum Rate Exhibit shows the components used in calculating change in

other. The calculations of the components are based on the changes in values shown in Table 7.

B. RETENTION ITEMS

Table 6 illustrates the retention items, expressed as percentages of premium. Consistent with

conversations with our State regulator, no Pricing load was applied for the Managed Care Assessment

levied pursuant to Article VIII-I of the Pennsylvania Code, as it will be separately reimbursed.

Administrative Expenses 14.55%

General and Claims 6.35%

Agent/Broker Fees and Commissions 7.40%

Quality Improvement Initiatives 0.80%

Taxes and Fees 0.52%

PCORI Fees 0.00%

PA Premium Tax 0.00%

Federal Income Tax 0.52%

Health Insurance Providers Fee1 0.00%

Profit/Contingency 2.00%

Total Retention 17.07%

1 – the annual trend in Table 5A includes an additional 2.9% to reflect the restoration of the HIF for

premiums due in 2020. The 2.9% is the HIF (2.145%) adjusted for federal income tax.

C. NORMALIZED MARKET-ADJUSTED PROJECTED ALLOWED TOTAL CLAIMS

Table 7 compares the normalization factors used in this filing to those used in the 2018 filing. The

changes in the factors reflect small differences from the projected populations in 2018 and 2019.


D. COMPONENTS OF RATE CHANGE

Table 8 illustrates the components of rate change, based on inputs form other sections of the Rate

Exhibits. The results in Row H are similar to the values in Row A of Table 8.

Data in Table 9 was taken from the 2018 URRT with the exceptions of Risk Adjustment and Reinsurance

which were revised to project company-specific values.

3. PLAN RATE DEVELOPMENT

Table 10 is populated with plan information consistent with entries in the 2019 URRT. Plan mappings,

where applicable, are illustrated in Column F of Table 10.

Attached to this actuarial memorandum are exhibits providing actuarial certifications for the use of

alternate methods of calculating the Actuarial Value, where applicable, as well as required support for

the calculations.

4. PLAN PREMIUM DEVELOPMENT FOR 21-YEAR OLD NON-TOBACCO USER

Table 11 is populated from other sections of the Rate Exhibits, along with the population by age and

rating area for the Projection Period.

5. PLAN FACTORS

Tables 12, 13, and 14 illustrate the factors used in pricing for age, tobacco, geographic rating area, and

network. The tobacco factors match the previously approved tobacco factors from the 2018 filing.

6. ACTUARIAL CERTIFICATION

I, XXXXXXXXXXXX, am Director & Actuary of Commercial Markets for the Independence Blue Cross Family of Companies. I am a member of the Society of Actuaries and the American Academy of Actuaries with the education and experience necessary to perform the work necessary and meet the Qualification Standards of the American Academy of Actuaries to render the qualified actuarial opinion contained herein. The developed rates and memorandum have been prepared in conformity with appropriate Actuarial Standards of Practice and the Academy’s Code of Professional Conduct. The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the premium rates and allowable rating factors. Rather, it represents information required by


Federal regulation to be provided in support of the review of gross premium rate increases, for certification of qualified health plans for Federally facilitated exchanges, and for certification that the index rate is developed in accordance with Federal regulation and used consistently and only adjusted by the allowable modifiers. I hereby certify that, to the best of my knowledge and judgment, the following:

▪ The projected index rate is:

—In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.08(d)(1) and 147.106);

—Developed in compliance with applicable Actuarial Standards of Practice;

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

—Neither excessive nor deficient.

▪ The index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2) were used to generate plan level rates.

▪ The percent of total premium that represents essential health benefits included in Worksheet 2, Sections III and IV were calculated in accordance with actuarial standards of practice.

▪ The AV Calculator was used to determine the AV Metal Values illustrated in Worksheet 2 of

the Part I Unified Rate Review Template for all plans, unless an alternate methodology was

required. If an alternate methodology was used to calculate the AV Metal Value for at least

one plan offered, a copy of the actuarial certification required by 45 CFR Part 156, §156.135

will be included.

▪ All factor, benefit, and other changes from the prior approved filing have been disclosed in

the actuarial memorandum.

▪ New plans cannot be considered modifications of existing plans under the uniform

modification standards in 45 CFR 147.106.

▪ The information presented in the PA Actuarial Memorandum and PA Actuarial

Memorandum Rate Exhibits is consistent with the information presented in the 2019 Rate

Filing Justification.

XXXXXXXXXXXX XXXXXXXXXXXX May 21, 2018

PA Rate Template Part IData Relevant to the Rate Filing

Table 0. Identifying Information

Carrier Name: KHPE Insurance Company, Inc.Product(s): HMOMarket Segment: Small GroupRate Effective Date: 1/1/2019 to 12/31/2019Base Period Start Date 1/1/2017 to 12/31/2017Date of Most Recent Membership 2/1/2018

Table 1. Number of Members

Member‐months Members Member‐months

Experience PeriodCurrent Period

(as of 02‐01‐2018)Projected Rating Period

Average Age 35.9 36.0 36.0

Total 1,429,195 114,365 1,372,380<18 259,379 20,642 247,70418‐24 138,261 10,520 126,24025‐29 133,392 10,865 130,38030‐34 133,819 10,923 131,07635‐39 122,460 10,061 120,73240‐44 107,942 8,821 105,85245‐49 127,942 10,120 121,44050‐54 142,456 11,170 134,04055‐59 138,688 11,051 132,61260‐63 93,476 7,696 92,35264+ 31,380 2,496 29,952*Tables 1, 2 and 4 must include data for all non‐grandfathered business (ACA compliant and Transitional

Table 2. Experience Period Claims and Premiums

Earned Premium Paid Claims Ultimate Incurred Claims Member MonthsEstimated Cost Sharing

(Member & HHS)Allowed Claims (Non‐Capitated)

Non‐EHB portion of Allowed Claims

Total Prescription Drug Rebates* Total EHB Capitation Total Non‐EHB Capitation Estimated Risk Adjustment

$ 700,305,217.35 $ 332,428,570.65 $ 339,815,616.74 1,429,195 $ 88,878,485.56 $ 428,694,102.30 ($13,361,744) $ 124,905,001.08 (54,176,451.22)$ Experience Period Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 378.00$ Loss Ratio 69.86%*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Induced Demand* Composite URRT Trend ** Weight*3.83% 1.49% 0.00% 5.38% 14.52%3.55% 1.49% 0.00% 5.09% 15.13%1.27% 1.49% 0.00% 2.78% 16.31%1.27% 1.49% 0.00% 2.78% 0.00%

15.00% 22.25%3.00% 1.61% 0.00% 4.65% 31.80%

6.92% 100.00%24

1.143* Express Cost, Utilization, Induced Utilization and Weight as percentages** Should = URRT Trend

Table 4. Historical Experience

Month‐Year Total Annual Premium Incurred Claims Completion Factors* Ultimate Incurred Claims Members Ultimate Incurred PMPMEstimated Annual Cost Sharing

(Member + HHS)Prescription Drug Rebates**

Allowed Claims (Net of Prescription Drug Rebates)

Allowed PMPM

Jan‐14 $ 40,604,302.32 1.0000 $ 40,604,302.32 316,387 $ 128.34 $ ‐ Feb‐14 $ 34,166,292.36 1.0000 $ 34,166,292.36 301,899 $ 113.17 $ ‐ Mar‐14 $ 39,338,046.68 1.0000 $ 39,338,046.68 282,712 $ 139.15 $ ‐ Apr‐14 $ 41,450,398.48 1.0000 $ 41,450,398.48 257,248 $ 161.13 $ ‐ May‐14 $ 40,797,001.60 1.0000 $ 40,797,001.60 242,959 $ 167.92 $ ‐ Jun‐14 $ 38,230,510.58 1.0000 $ 38,230,510.58 225,177 $ 169.78 $ ‐ Jul‐14 $ 42,003,525.81 1.0000 $ 42,003,525.81 208,509 $ 201.45 $ ‐

Aug‐14 $ 38,398,241.23 1.0000 $ 38,398,241.23 195,609 $ 196.30 $ ‐ Sep‐14 $ 40,788,043.11 1.0000 $ 40,788,043.11 179,173 $ 227.65 $ ‐ Oct‐14 $ 41,520,340.29 1.0000 $ 41,520,340.29 165,793 $ 250.43 $ ‐ Nov‐14 $ 35,480,336.72 1.0000 $ 35,480,336.72 153,360 $ 231.35 $ ‐ Dec‐14 $ 40,242,044.94 1.0000 $ 40,242,044.94 126,131 $ 319.05 $ ‐ Jan‐15 $ 47,920,822.35 1.0000 $ 47,920,822.35 125,009 $ 383.34 $ ‐ Feb‐15 $ 44,150,845.02 1.0000 $ 44,150,845.02 124,735 $ 353.96 $ ‐ Mar‐15 $ 47,088,110.55 1.0000 $ 47,088,110.55 124,684 $ 377.66 $ ‐ Apr‐15 $ 46,649,913.22 1.0000 $ 46,649,913.22 124,297 $ 375.31 $ ‐ May‐15 $ 43,834,781.73 1.0000 $ 43,834,781.73 123,986 $ 353.55 $ ‐ Jun‐15 $ 45,917,347.66 1.0000 $ 45,917,347.66 123,538 $ 371.69 $ ‐ Jul‐15 $ 46,642,687.61 1.0000 $ 46,642,687.61 123,094 $ 378.92 $ ‐



Aug‐17 $ 29,538,324.24 0.9809 $ 30,112,953.78 118,347 $ 254.45 $ ‐ Sep‐17 $ 27,675,187.99 0.9759 $ 28,358,832.93 118,515 $ 239.28 $ ‐ Oct‐17 $ 28,831,361.93 0.9707 $ 29,702,909.84 118,283 $ 251.12 $ ‐ Nov‐17 $ 27,642,604.84 0.9605 $ 28,780,210.75 118,198 $ 243.49 $ ‐ Dec‐17 $ 24,041,404.14 0.9472 $ 25,380,229.95 116,849 $ 217.21 $ ‐

* Express Completion Factor as a percentage**Express Prescription Drug Rebates as a negative number

Service CategoryInpatient HospitalOutpatient Hospital

Total Applied Trend Projection Factor

ProfessionalOther Medical CapitationPrescription DrugsTotal Annual TrendMonths of Trend

$ 632,859,798.00 $ 31,993,226.00

$ 700,305,217.35 $ 88,878,485.56

$ 671,931,345.00 $ 22,793,366.00

$ 699,143,181.89 $ 118,977,223.38

Carrier Name: KHPE Insurance Company, Inc.Product(s): HMOMarket Segment: Small GroupRate Effective Date: 1/1/2019

Table 2b. Manual Experience Period Claims and Premiums

Earned Premium Paid Claims Ultimate Incurred Claims Member MonthsEstimated Cost Sharing

(Member & HHS)Allowed Claims (Non‐Capitated)

Non‐EHB portion of Allowed Claims

Total Prescription Drug Rebates* Total EHB Capitation Total Non‐EHB Capitation Estimated Risk Adjustment

Experience Period Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) ‐$ Loss Ratio 0.00%*Express Prescription Drug Rebates as a negative number

Table 3b. Manual Trend Components

Cost* Utilization* Induced Utilization* Composite URRT Trend** Weight*0.00%0.00%0.00%0.00%

0.00%0.00% 0.00%24

1.000* Express Cost, Utilization, Induced Utilization and Weight as percentages** Should = URRT Trend

Table 4b. Historical Manual Experience

Month‐Year Total Annual Premium Incurred Claims Completion Factors* Ultimate Incurred Claims Members Ultimate Incurred PMPMEstimated Annual Cost Sharing

(Member + HHS)Prescription Drug Rebates**

Allowed Claims (Net of Prescription Drug Rebates)

Allowed PMPM

Jan‐14 #DIV/0! #DIV/0! #DIV/0!Feb‐14 #DIV/0! #DIV/0! #DIV/0!Mar‐14 #DIV/0! #DIV/0! #DIV/0!Apr‐14 #DIV/0! #DIV/0! #DIV/0!May‐14 #DIV/0! #DIV/0! #DIV/0!Jun‐14 #DIV/0! #DIV/0! #DIV/0!Jul‐14 #DIV/0! #DIV/0! #DIV/0!

Aug‐14 #DIV/0! #DIV/0! #DIV/0!Sep‐14 #DIV/0! #DIV/0! #DIV/0!Oct‐14 #DIV/0! #DIV/0! #DIV/0!Nov‐14 #DIV/0! #DIV/0! #DIV/0!Dec‐14 #DIV/0! #DIV/0! #DIV/0!Jan‐15 #DIV/0! #DIV/0! #DIV/0!Feb‐15 #DIV/0! #DIV/0! #DIV/0!Mar‐15 #DIV/0! #DIV/0! #DIV/0!Apr‐15 #DIV/0! #DIV/0! #DIV/0!May‐15 #DIV/0! #DIV/0! #DIV/0!Jun‐15 #DIV/0! #DIV/0! #DIV/0!Jul‐15 #DIV/0! #DIV/0! #DIV/0!



Aug‐17 #DIV/0! #DIV/0! #DIV/0!Sep‐17 #DIV/0! #DIV/0! #DIV/0!Oct‐17 #DIV/0! #DIV/0! #DIV/0!Nov‐17 #DIV/0! #DIV/0! #DIV/0!Dec‐17 #DIV/0! #DIV/0! #DIV/0!

* Express Completion Factor as a percentage**Express Prescription Drug Rebates as a negative number

Capitation

Service CategoryInpatient HospitalOutpatient HospitalProfessionalOther Medical

Prescription DrugsTotal Annual TrendMonths of TrendTotal Applied Trend Projection Factor

PA Rate Template Part IIRate Development and ChangeCarrier Name: KHPE Insurance Company, Inc.Product(s): HMO

Market Segment: Small Group

Rate Effective Date: 1/1/2019

Table 5. Development of the Projected Index Rate, Market‐Adjusted Index Rate, and Total Allowed Claims

Development of the Projected Index RateActual Experience

DataManual Data

Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) PMPM 378.00$ ‐$ <‐ Actual Experience PMPM should be consistent with the Index Rate for Experience Period on URRT

Two year trend projection Factor 1.143 1.000

Unadjusted Projected Allowed EHB Claims PMPM 432.09$ ‐$ For Informational Purposes only ‐ No input required.

Single Risk Pool Adjustment Factors

Change in Morbidity 1.000 <‐ See URRT Instructions Blended Base Period Unadjusted Claims before Normalization 378.00$ <‐ Index Rate of Experience Period on URRT

Change in Other 1.012 0.000 Blended Earned Premium 700,305,217.35$

Change in Demographics 1.019 <‐ See URRT Instructions Blended Loss Ratio 69.86%

Change in Network 0.993 <‐ See URRT Instructions

Change in Benefits 1.000 <‐ See URRT Instructions

Change in Other 1.000 <‐ See URRT Instructions

Total Adjusted Projected Allowed EHB Claims PMPM 437.36$ ‐$

Credibidility Factors 100% 0% <‐ See Instructions

Blended Projected EHB Claims PMPM 437.36$ <‐ Projected Index Rate

Development of the Market‐Adjusted Index Rate and Total Allowed Claims

Adjusted Projected Allowed EHB Claims PMPM 437.36$ <‐ Index Rate for Projection Period on URRT ‐ Individual or First Quarter Small Group Table 5A. Small Group Projected Index Rate with Quarterly TrendAdjusted Projected Allowed EHB Claims PMPM [will only populate for small group filings] 451.96$ Projected Paid to Allowed Ratio 0.846 <‐ Paid to Allowed Average Factor in Projection Period on URRT Effective Date 1/1/2019 4/1/2019 7/1/2019 10/1/2019 Total Single Risk PoolProjected Paid EHB Claims PMPM 382.41$ # of Member Months Renewing in Quarter 517,646 307,771 230,182 365,315 1,420,914 Market‐wide Adjustments Adjusted Projected Allowed EHB Claims PMPM Q1 437.36$ 437.36$ 437.36$ 437.36$ 437.36$ Projected Risk Adjustment PMPM ($70.57) Months of Trend ‐ 3 6 9 Projected Paid Exchange User Fees PMPM ‐$ Annual Trend ################## 10.38% 10.38% 10.38%

Single Risk Pool Projected Allowed Claims 437.36$ 448.29$ 459.50$ 470.99$ 451.96$ Market‐Adjusted Projected Paid EHB Claims PMPM 452.97$ Quarterly Trend Factor 100.0% 102.5% 105.1% 107.7% 103.3%

2019 Trend Factors by Quarter 0.9677 0.9919 1.0167 1.0421Market‐Adjusted Projected Allowed EHB Claims PMPM 535.36$ <‐ Market‐Adjusted Index Rate

Projected Allowed Non‐EHB Claims PMPM 1.07$

Market‐Adjusted Projected Paid Total Claims PMPM 453.88$

Market‐Adjusted Projected Allowed Total Claims PMPM 536.43$

Table 6. Retention Table 7. Normalized Market‐Adjusted Projected Allowed Total Claims

Retention Items ‐ Express in percentages Percentages PMPM Amounts Normalization Factors 2018 2019Administrative Expenses 14.55% $79.62 Average Age Factor 1.447 1.475 General and Claims 6.35% $34.75 Average Geographic Factor 1.000 1.000 Agent/Broker Fees and Commissions 7.40% $40.50 Average Tobacco Factor 1.011 1.011 Quality Improvement Initiatives 0.80% $4.38 Average Benefit Richness (induced demand) 0.947 0.947Taxes and Fees 0.52% $2.85 Average Network Factor 1.011 1.011 PCORI Fees 0.00% $0.00 PA Premium Tax (if applicable) 0.00% $0.00 Market‐Adjusted Projected Allowed Total Claims PMPM 512.70$ 536.43$ Federal Income Tax 0.52% $2.85 Health Insurance Providers Fee (Prorated for Small Groups only) 0.00% $0.00 Normalized Market‐Adjusted Projected Allowed Total Claims PMPM 366.04$ 375.74$

Profit/Contingency (after tax) 2.00% $10.95

Total Retention 17.07% $93.42

Projected Required Revenue PMPM 547.30$ <‐ Single Pool Gross Premium Avg. Rate, PMPM on URRT

Table 8. Components of Rate Change Table 9. Year‐over‐Year Data to Support Table 8

Rate Components 2018 2019 Difference Percent Change 2018 2019A. Calibrated Plan Adjusted Index Rate (PMPM) 356.66$ 371.85$ $15.20 4.3% Paid‐to‐Allowed 0.880 0.846

B. Base period allowed claims before normalization 411.53$ 378.00$ ‐$33.53 ‐9.4% URRT Trend (Total Applied Trend Factor) 1.167 1.143 <‐ URRT W1, S2 C. Normalization factor component of change (117.72)$ (113.24)$ $4.48 1.3% URRT Morbidity 1.000 1.000 <‐ URRT W1, S2

URRT "Other" 1.025 1.012 <‐ URRT W1, S2D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 293.81$ 264.77$ (29.05)$ ‐8.1% Risk Adjustment 9.045 70.57$ <‐ URRT W1, S3 D2. URRT Trend 48.93$ 37.88$ (11.05)$ ‐3.1% Exchange User Fee 0.000 ‐$ <‐ URRT W1, S3 D3. URRT Morbidity ‐$ ‐$ ‐$ 0.0% Capitation 0.000 <‐ URRT W1, S2 D4. URRT Other 8.40$ 3.69$ (4.71)$ ‐1.3% D5. Normalized URRT RA/RI on an allowed basis 7.34$ 58.42$ 51.08$ 14.3% Network 1.009 1.011 D6. Normalized Exchange User Fee on an allowed basis ‐$ ‐$ ‐$ 0.0% Pricing AV 0.851 0.846 D7. Subtotal ‐ Sum(D1:D6) 358.49$ 364.76$ 6.28$ 1.8% Benefit Richness 0.942 0.947E. Change in Allowable Plan Adjusted Level Components Catastrophic Eligibility 1.000 1.000 E1. Network 3.19$ 4.01$ 0.82$ 0.2% E2. Pricing AV (54.05)$ (56.75)$ (2.71)$ ‐0.8% Administrative Expenses 0.146 14.55% E3. Benefit Richness (17.80)$ (16.54)$ 1.26$ 0.4% Taxes and Fees 0.014 0.52% E4. Catastrophic Eligibility ‐$ ‐$ ‐$ 0.0% Profit and/or Contingency 0.020 2.00% E5. Subtotal ‐ Sum(E1:E4) (68.65)$ (69.28)$ (0.63)$ ‐0.2%F. Change in Retention Components F1. Administrative Expenses 51.89$ 54.10$ 2.21$ 0.6% F2. Taxes and Fees 4.96$ 1.93$ (3.02)$ ‐0.8% F3. Profit and/or Contingency 7.13$ 7.44$ 0.30$ 0.1% F4. Subtotal ‐ Sum(F1:F3) 63.98$ 63.47$ (0.51)$ ‐0.1%

G. Change in Miscellaneous Items ‐$ 0.0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 353.82$ 358.95$ 5.13$ 1.4%

PA Rate Template Part IIITable 10. Plan Rates

Age Calibration Factor 1.475Carrier Name: KHPE Insurance Company, Inc. Geographic Calibration Factor 1.000Product(s): HMO Tobacco Calibration Factor 1.011Market Segment: Small Group Aggregate Calibration Factor 1.491Rate Effective Date: 1/1/2019Base Period Start Date 1/1/2017Date of Most Recent Membership 2/1/2018Market Adjusted Index Rate 535.36$

Plan Number

HIOS Plan ID (Standard

Component)

Plan Type (HMO, POS, PPO, EPO, Indemnity, Other)

1/1/2018 Plan Marketing Name

Existing, Modified, New, Discontinued &

Mapped, Discontinued & Not Mapped (E,M,N,DM,

DNM) for 2019

1/1/2019 Plan HIOS Plan ID (If 1/1/2018 Plan Discontinued &

Mapped)Metallic Tier

Metallic Tier Actuarial Value

Standard AV, Approach (1), Approach (2)

Exchange On/Off or

Off

Pricing AV (company‐determined

AV)

Benefit Richness (induced demand)

Benefits in addition to

EHBProvider Network

Catastrophic Eligibility

Non‐Funding of CSR

Adjustment Pure Premium Admin Costs

Taxes & Fees (not including Exchange

fees)Profit or

Contingency

Total Covered Lives

Mapped into 2019 Plans @ 02‐01‐

2018Total Policyholders

@ 02‐01‐2018

2018 Calibrated Plan Adjusted Index Rate PMPM

2019 Calibrated Plan Adjusted Index Rate PMPM

Proposed Rate Change

Compared to Prior 12 months

% of Total Covered Lives 1 2 3 4 5 6 7 8 9 Total

2019 Continued/ Discontined

Plans Indicator

Totals 0.789 0.846 1.000 1.002 1.000 1.000 1.000 459.85$ 14.5% 0.5% 2.0% 114,083 16,061 356.66$ 371.85$ 4.3% ‐ ‐ ‐ ‐ ‐ ‐ ‐ 114,861 ‐ 114,861

Transitional Plans TRANSITIONAL N/A TRANSITIONAL DNM TRANSITIONAL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ‐ N/A N/A N/A N/A ‐ 0

Plan 1 33871PA0100001 HMOKeystone HMO Platinum Preferred $10/$20/$100 DM 33871PA0100020 Platinum 0.92 Standard AV Off 0.974 1.155 1.002 1.036 1.000 1.000 624.8596447 14.5% 0.5% 2.0% 8 2 483.84$ 505.28$ 4.4% 7.01244E‐05 8 8 1

Plan 2 33871PA0100002 HMOKeystone HMO Platinum Preferred $20/$40/$150 DM 33871PA0100021 Platinum 0.896 Standard AV Off 0.964 1.115 1.002 1.036 1.000 1.000 $597.38 14.5% 0.5% 2.0% 10 3 462.54$ 483.06$ 4.4% 0.0% 10 10 1

Plan 3 33871PA0100003 HMOKeystone HMO Gold Preferred $30/$60/$600 DM 33871PA0100022 Gold 0.819 Standard AV Off 0.869 1.014 1.002 1.036 1.000 1.000 $489.30 14.5% 0.5% 2.0% 13 6 380.87$ 395.67$ 3.9% 0.0% 13 13 1

Plan 4 33871PA0100004 HMOKeystone HMO Gold Classic $1,000 $25/$50/90% DM 33871PA0100023 Gold 0.811 Approach 1 Off 0.832 1.061 1.002 1.036 1.000 1.000 $490.19 14.5% 0.5% 2.0% 11 3 393.95$ 396.38$ 0.6% 0.0% 11 11 1

Plan 5 33871PA0100006 HMOKeystone HMO Silver Classic $3,250/$30/$60/50% DM 33871PA0100025 Silver 0.714 Standard AV Off 0.757 0.963 1.002 1.036 1.000 1.000 $405.09 14.5% 0.5% 2.0% 2 2 316.21$ 327.57$ 3.6% 0.0% 2 2 1

Plan 6 33871PA0100007 HMOKeystone HMO Bronze Essential $6,850/$50/$100/$700 DM 33871PA0100026 Bronze 0.635 Approach 1 Off 0.685 0.815 1.002 1.036 1.000 1.000 $309.95 14.5% 0.5% 2.0% 3 2 239.23$ 250.64$ 4.8% 0.0% 3 3 1

Plan 7 33871PA0100008 HMO Keystone HMO Gold Proactive DM 33871PA0100044 Gold 0.767 Approach 2 On 0.871 1.010 1.002 0.941 1.000 1.000 $444.48 14.5% 0.5% 2.0% 19 8 341.22$ 359.42$ 5.3% 0.0% 19 19 1Plan 8 33871PA0100009 HMO Keystone HMO Silver Proactive DM 33871PA0100045 Silver 0.719 Approach 2 Off 0.768 0.871 1.002 0.941 1.000 1.000 $337.94 14.5% 0.5% 2.0% 217 51 260.01$ 273.27$ 5.1% 0.2% 217 217 1

Plan 9 33871PA0110003 POSKeystone DPOS Gold Preferred $30/$60/$600 DM 33871PA0110013 Gold 0.819 Standard AV Off 0.868 1.059 1.002 1.036 1.000 1.000 $510.52 14.5% 0.5% 2.0% 10 5 397.84$ 412.82$ 3.8% 0.0% 10 10 1

Plan 10 33871PA0110004 POSKeystone DPOS Gold Classic $1,000 $25/$50/90% DM 33871PA0110014 Gold 0.811 Approach 1 Off 0.832 1.104 1.002 1.036 1.000 1.000 $510.39 14.5% 0.5% 2.0% 8 2 410.18$ 412.72$ 0.6% 0.0% 8 8 1

Plan 11 33871PA0110006 POSKeystone DPOS Silver Classic $4,000/$25/$50/70% DM 33871PA0110016 Silver 0.719 Approach 1 Off 0.765 1.008 1.002 1.036 1.000 1.000 $428.36 14.5% 0.5% 2.0% 1 1 335.23$ 346.39$ 3.3% 0.0% 1 1 1

Plan 12 33871PA0110010 POS

Keystone DPOS Bronze Essential $6,850/$50/$100/$700

DM 33871PA0110020 Bronze 0.635 Approach 1 Off 0.684 0.850 1.002 1.036 1.000 1.000 $322.89 14.5% 0.5% 2.0% 19 4 249.58$ 261.10$ 4.6% 0.0% 19 19 1

Plan 13 33871PA0110005 POSKeystone DPOS Gold Classic $2,000 $40/$80/100% DNM Gold 0.818 Approach 1 ON/OFF 0.856 1.060 1.002 1.036 1.000 1.000 $504.12 14.5% 0.5% 2.0% ‐ 1 393.79$ 407.65$ 3.5% 0.0% 4 4 0

Plan 14 33871PA0100020 HMOKeystone HMO Platinum Preferred $10/$20/$150 E Platinum 0.92 Standard AV OFF 0.974 1.155 1.002 1.036 1.000 1.000 $624.86 14.5% 0.5% 2.0% 2,275 363 483.84$ 505.28$ 4.4% 2.0% 2,275 2,275 1

Plan 15 33871PA0100021 HMOKeystone HMO Platinum Preferred $20/$40/$200 E Platinum 0.896 Standard AV OFF 0.964 1.115 1.002 1.036 1.000 1.000 $597.38 14.5% 0.5% 2.0% 7,330 998 462.54$ 483.06$ 4.4% 6.4% 7,330 7,330 1

Plan 16 33871PA0100022 HMOKeystone HMO Gold Preferred $35/$70/$650 E Gold 0.819 Standard AV OFF 0.869 1.014 1.002 1.036 1.000 1.000 $489.30 14.5% 0.5% 2.0% 24,892 3,483 380.87$ 395.67$ 3.9% 21.8% 24,892 24,892 1

Plan 17 33871PA0100023 HMOKeystone HMO Gold Classic $1,500/$25/$50/90% E Gold 0.811 Approach 1 OFF 0.832 1.061 1.002 1.036 1.000 1.000 $490.19 14.5% 0.5% 2.0% 1,145 209 393.95$ 396.38$ 0.6% 1.0% 1,145 1,145 1

Plan 18 33871PA0100024 HMOKeystone HMO Silver Classic $4,250/$25/$50/70% E Silver 0.719 Approach 1 OFF 0.764 0.965 1.002 1.036 1.000 1.000 $409.58 14.5% 0.5% 2.0% 2,757 475 320.95$ 331.20$ 3.2% 2.4% 2,757 2,757 1

Plan 19 33871PA0100025 HMOKeystone HMO Silver Classic $3,250/$30/$60/50% E Silver 0.714 Standard AV OFF 0.757 0.963 1.002 1.036 1.000 1.000 $405.09 14.5% 0.5% 2.0% 1,427 275 316.21$ 327.57$ 3.6% 1.3% 1,427 1,427 1

Plan 20 33871PA0100026 HMOKeystone HMO Bronze Essential $6,850/$50/$100/$700 E Bronze 0.635 Approach 1 OFF 0.685 0.815 1.002 1.036 1.000 1.000 $309.95 14.5% 0.5% 2.0% 2,257 542 239.23$ 250.64$ 4.8% 2.0% 2,257 2,257 1

Plan 21 33871PA0110011 POSKeystone DPOS Platinum Preferred $10/$20/$150 E Platinum 0.92 Standard AV OFF 0.973 1.208 1.002 1.036 1.000 1.000 $653.09 14.5% 0.5% 2.0% 3,205 394 506.21$ 528.11$ 4.3% 2.8% 3,205 3,205 1

Plan 22 33871PA0110012 POSKeystone DPOS Platinum Preferred $20/$40/$200 E Platinum 0.895 Standard AV OFF 0.963 1.167 1.002 1.036 1.000 1.000 $624.37 14.5% 0.5% 2.0% 7,426 919 483.94$ 504.88$ 4.3% 6.5% 7,426 7,426 1

Plan 23 33871PA0110013 POSKeystone DPOS Gold Preferred $35/$70/$650 E Gold 0.819 Standard AV OFF 0.868 1.059 1.002 1.036 1.000 1.000 $510.52 14.5% 0.5% 2.0% 10,027 1,225 397.84$ 412.82$ 3.8% 8.8% 10,027 10,027 1

Plan 24 33871PA0110014 POSKeystone DPOS Gold Classic $1,500/$25/$50/90% E Gold 0.811 Approach 1 OFF 0.832 1.104 1.002 1.036 1.000 1.000 $510.39 14.5% 0.5% 2.0% 2,201 312 410.18$ 412.72$ 0.6% 1.9% 2,201 2,201 1

Plan 25 33871PA0110016 POSKeystone DPOS Silver Classic $4,250/$25/$50/70% E Silver 0.719 Approach 1 OFF 0.765 1.008 1.002 1.036 1.000 1.000 $428.36 14.5% 0.5% 2.0% 1,251 213 335.23$ 346.39$ 3.3% 1.1% 1,251 1,251 1

Plan 26 33871PA0110019 POSKeystone DPOS Silver Classic $3,250/$30/$60/50% E Silver 0.714 Standard AV OFF 0.757 1.006 1.002 1.036 1.000 1.000 $423.01 14.5% 0.5% 2.0% 1,085 204 330.19$ 342.06$ 3.6% 1.0% 1,085 1,085 1

Plan 27 33871PA0110020 POSKeystone DPOS Bronze Essential $6,850/$50/$100/$700 E Bronze 0.635 Approach 1 OFF 0.684 0.850 1.002 1.036 1.000 1.000 $322.89 14.5% 0.5% 2.0% 566 123 249.58$ 261.10$ 4.6% 0.5% 566 566 1

Plan 28 33871PA0110007 POSKeystone DPOS Silver Secure $3,500 $40/$80/$600 DNM Silver 0.693 Approach 1 ON/OFF 0.749 0.946 1.002 1.036 1.000 1.000 $393.67 14.5% 0.5% 2.0% ‐ 1 306.49$ 318.33$ 3.9% 0.0% 3 3 0

Plan 29 33871PA0100035 HMOKeystone HMO Gold Classic $2,000 $40/$80/100% DM 33871PA0100047 Gold 0.808 Approach 1 ON/OFF 0.854 1.054 1.002 1.036 1.000 1.000 $500.18 14.5% 0.5% 2.0% 4 2 391.62$ 404.46$ 3.3% 0.0% 4 4 1

Plan 30 33871PA0100037 HMOKeystone HMO Silver Secure $4,500/$40/$80/$600 DM 33871PA0100049 Silver 0.718 Approach 1 ON/OFF 0.744 0.927 1.002 1.036 1.000 1.000 $383.23 14.5% 0.5% 2.0% 2 1 300.37$ 309.89$ 3.2% 0.0% 2 2 1

Plan 31 33871PA0110015 POSKeystone DPOS Gold Classic $2,000 $40/$80/100% DNM Gold 0.818 Approach 1 OFF 0.860 1.100 1.002 1.036 1.000 1.000 $525.57 14.5% 0.5% 2.0% ‐ 46 408.63$ 424.99$ 4.0% 0.0% 433 433 0

Plan 32 33871PA0110018 POSKeystone DPOS Silver Classic $4,250 $40/$80/100% DNM Silver 0.717 Approach 1 OFF 0.760 1.034 1.002 1.036 1.000 1.000 $436.42 14.5% 0.5% 2.0% ‐ 33 339.32$ 352.90$ 4.0% 0.0% 181 181 0

Plan 33 33871PA0110017 POSKeystone DPOS Silver Secure $3,500 $40/$80/$600 DNM Silver 0.719 Standard AV OFF 0.749 0.982 1.002 1.036 1.000 1.000 $408.81 14.5% 0.5% 2.0% ‐ 31 318.27$ 330.57$ 3.9% 0.0% 157 157 0

Plan 34 33871PA0100044 HMO Keystone HMO Gold Proactive E Gold 0.767 Approach 2 OFF 0.871 1.010 1.002 0.941 1.000 1.000 $444.48 14.5% 0.5% 2.0% 13,676 1,816 341.22$ 359.42$ 5.3% 12.0% 13,676 13,676 1Plan 35 33871PA0100045 HMO Keystone HMO Silver Proactive E Silver 0.719 Approach 2 OFF 0.768 0.871 1.002 0.941 1.000 1.000 $337.94 14.5% 0.5% 2.0% 29,238 3,837 260.01$ 273.27$ 5.1% 25.6% 29,238 29,238 1

Plan 36 33871PA0100047 HMOKeystone HMO Gold Classic $2,500/$40/$80/100% E Gold 0.808 Approach 1 OFF 0.854 1.054 1.002 1.036 1.000 1.000 $500.18 14.5% 0.5% 2.0% 673 111 391.62$ 404.46$ 3.3% 0.6% 673 673 1

Plan 37 33871PA0100048 HMOKeystone HMO Silver Classic $4,500/$40/$80/100% E Silver 0.717 Approach 1 OFF 0.742 0.975 1.002 1.036 1.000 1.000 $401.77 14.5% 0.5% 2.0% 1,319 168 311.54$ 324.89$ 4.3% 1.2% 1,319 1,319 1

Plan 38 33871PA0100049 HMOKeystone HMO Silver Secure $5,000/$40/$80/$600 E Silver 0.718 Standard AV OFF 0.744 0.927 1.002 1.036 1.000 1.000 $383.23 14.5% 0.5% 2.0% 855 173 300.37$ 309.89$ 3.2% 0.7% 855 855 1

Plan 39 33871PA0100050 HMOKeystone HMO Platinum Preferred $30/$60/$400 E Platinum 0.866 Standard AV OFF 0.946 1.072 1.002 1.036 1.000 1.000 $563.61 14.5% 0.5% 2.0% 151 17 435.43$ 455.76$ 4.7% 0.1% 151 151 1

Plan 40 $0.00 ‐ ‐ ‐$ 0.0% 0.0% ‐ ‐ 0Plan 41 $0.00 ‐ ‐ ‐$ 0.0% 0.0% ‐ ‐ 0

02‐01‐2018 Number of Covered Lives by Rating Area

Calibration Total Covered Lives @ 02‐01‐2018114,365

45 CFR Part 156.8 (d) (2) Allowable Factors

PA Rate Template Part IV B ‐ Small Group AnnualTable 11. Plan Premium Development for 21‐Year‐Old Non‐Tobacco User

Carrier Name: KHPE Insurance Company, Inc.Product(s): HMOMarket Segment: Small GroupRate Effective Date: 1/1/2019

Plan NumberHIOS Plan ID (Standard

Component)1/1/2018 Plan

Marketing Name

Discontinued, New, Modified,

Existing (D,N,M,E) for

2019

1/1/2019 Plan HIOS Plan ID (If 1/1/2018 Plan

Discontinued & Mapped) Metallic Tier

Exchange On/Off or

Off 1 2 3 4 5 6 7 8 9

Average (weighted

by enrollment by rating area)

Totals ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 357.93$ ‐$ 357.93$

Plan 1 33871PA0100001 Keystone HMO Platinum Preferred $10/$20/$100 DM 33871PA0100020 Platinum Off 485.57$ 485.57$ Plan 2 33871PA0100002 Keystone HMO Platinum Preferred $20/$40/$150 DM 33871PA0100021 Platinum Off 464.20$ 464.20$ Plan 3 33871PA0100003 Keystone HMO Gold Preferred $30/$60/$600 DM 33871PA0100022 Gold Off 382.24$ 382.24$ Plan 4 33871PA0100004 Keystone HMO Gold Classic $1,000 $25/$50/90% DM 33871PA0100023 Gold Off 395.36$ 395.36$ Plan 5 33871PA0100006 Keystone HMO Silver Classic $3,250/$30/$60/50% DM 33871PA0100025 Silver Off 317.34$ 317.34$ Plan 6 33871PA0100007 Keystone HMO Bronze Essential $6,850/$50/$100/$700 DM 33871PA0100026 Bronze Off 240.09$ 240.09$ Plan 7 33871PA0100008 Keystone HMO Gold Proactive DM 33871PA0100044 Gold On 342.44$ 342.44$ Plan 8 33871PA0100009 Keystone HMO Silver Proactive DM 33871PA0100045 Silver Off 260.95$ 260.95$ Plan 9 33871PA0110003 Keystone DPOS Gold Preferred $30/$60/$600 DM 33871PA0110013 Gold Off 399.27$ 399.27$ Plan 10 33871PA0110004 Keystone DPOS Gold Classic $1,000 $25/$50/90% DM 33871PA0110014 Gold Off 411.66$ 411.66$ Plan 11 33871PA0110006 Keystone DPOS Silver Classic $4,000/$25/$50/70% DM 33871PA0110016 Silver Off 336.43$ 336.43$ Plan 12 33871PA0110010 Keystone DPOS Bronze Essen al $6,850/$50/$100/$700 DM 33871PA0110020 Bronze Off 250.48$ 250.48$ Plan 13 33871PA0110005 Keystone DPOS Gold Classic $2,000 $40/$80/100% DNM 0 Gold ON/OFF 395.20$ 395.20$ Plan 14 33871PA0100020 Keystone HMO Platinum Preferred $10/$20/$150 E 0 Platinum OFF 485.57$ 485.57$ Plan 15 33871PA0100021 Keystone HMO Platinum Preferred $20/$40/$200 E 0 Platinum OFF 464.20$ 464.20$ Plan 16 33871PA0100022 Keystone HMO Gold Preferred $35/$70/$650 E 0 Gold OFF 382.24$ 382.24$ Plan 17 33871PA0100023 Keystone HMO Gold Classic $1,500/$25/$50/90% E 0 Gold OFF 395.36$ 395.36$ Plan 18 33871PA0100024 Keystone HMO Silver Classic $4,250/$25/$50/70% E 0 Silver OFF 322.10$ 322.10$ Plan 19 33871PA0100025 Keystone HMO Silver Classic $3,250/$30/$60/50% E 0 Silver OFF 317.34$ 317.34$ Plan 20 33871PA0100026 Keystone HMO Bronze Essential $6,850/$50/$100/$700 E 0 Bronze OFF 240.09$ 240.09$ Plan 21 33871PA0110011 Keystone DPOS Platinum Preferred $10/$20/$150 E 0 Platinum OFF 508.03$ 508.03$ Plan 22 33871PA0110012 Keystone DPOS Platinum Preferred $20/$40/$200 E 0 Platinum OFF 485.67$ 485.67$ Plan 23 33871PA0110013 Keystone DPOS Gold Preferred $35/$70/$650 E 0 Gold OFF 399.27$ 399.27$ Plan 24 33871PA0110014 Keystone DPOS Gold Classic $1,500/$25/$50/90% E 0 Gold OFF 411.66$ 411.66$ Plan 25 33871PA0110016 Keystone DPOS Silver Classic $4,250/$25/$50/70% E 0 Silver OFF 336.43$ 336.43$ Plan 26 33871PA0110019 Keystone DPOS Silver Classic $3,250/$30/$60/50% E 0 Silver OFF 331.38$ 331.38$ Plan 27 33871PA0110020 Keystone DPOS Bronze Essential $6,850/$50/$100/$700 E 0 Bronze OFF 250.48$ 250.48$ Plan 28 33871PA0110007 Keystone DPOS Silver Secure $3,500 $40/$80/$600 DNM 0 Silver ON/OFF 307.59$ 307.59$ Plan 29 33871PA0100035 Keystone HMO Gold Classic $2,000 $40/$80/100% DM 33871PA0100047 Gold ON/OFF 393.03$ 393.03$ Plan 30 33871PA0100037 Keystone HMO Silver Secure $4,500/$40/$80/$600 DM 33871PA0100049 Silver ON/OFF 301.44$ 301.44$ Plan 31 33871PA0110015 Keystone DPOS Gold Classic $2,000 $40/$80/100% DNM 0 Gold OFF 410.10$ 410.10$ Plan 32 33871PA0110018 Keystone DPOS Silver Classic $4,250 $40/$80/100% DNM 0 Silver OFF 340.53$ 340.53$ Plan 33 33871PA0110017 Keystone DPOS Silver Secure $3,500 $40/$80/$600 DNM 0 Silver OFF 319.41$ 319.41$ Plan 34 33871PA0100044 Keystone HMO Gold Proactive E 0 Gold OFF 342.44$ 342.44$ Plan 35 33871PA0100045 Keystone HMO Silver Proactive E 0 Silver OFF 260.95$ 260.95$ Plan 36 33871PA0100047 Keystone HMO Gold Classic $2,500/$40/$80/100% E 0 Gold OFF 393.03$ 393.03$ Plan 37 33871PA0100048 Keystone HMO Silver Classic $4,500/$40/$80/100% E 0 Silver OFF 312.65$ 312.65$ Plan 38 33871PA0100049 Keystone HMO Silver Secure $5,000/$40/$80/$600 E 0 Silver OFF 301.44$ 301.44$ Plan 39 33871PA0100050 Keystone HMO Platinum Preferred $30/$60/$400 E 0 Platinum OFF 437.00$ 437.00$ Plan 40 0 0 0 0 0 0 ‐$ Plan 41 0 0 0 0 0 0 ‐$

These cells auto‐fill using the data entered in Table 10.

Quarter 1 2018, 21‐year‐old Non‐Tobacco Premium PMPM

1 2 3 4 5 6 7 8 9

Average (weighted

by enrollment by rating area) 1 2 3 4 5 6 7 8 9

Average (weighted


‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 359.84$ ‐$ 359.84$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.6% 0.0% 0.6%

‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 488.96$ ‐$ 488.96$ 0.7% 0.7%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 467.46$ ‐$ 467.46$ 0.7% 0.7%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 382.89$ ‐$ 382.89$ 0.2% 0.2%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 383.58$ ‐$ 383.58$ ‐3.0% ‐3.0%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 316.99$ ‐$ 316.99$ ‐0.1% ‐0.1%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 242.54$ ‐$ 242.54$ 1.0% 1.0%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 347.81$ ‐$ 347.81$ 1.6% 1.6%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 264.44$ ‐$ 264.44$ 1.3% 1.3%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 399.49$ ‐$ 399.49$ 0.1% 0.1%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 399.39$ ‐$ 399.39$ ‐3.0% ‐3.0%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 335.20$ ‐$ 335.20$ ‐0.4% ‐0.4%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 252.67$ ‐$ 252.67$ 0.9% 0.9%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 394.48$ ‐$ 394.48$ ‐0.2% ‐0.2%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 488.96$ ‐$ 488.96$ 0.7% 0.7%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 467.46$ ‐$ 467.46$ 0.7% 0.7%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 382.89$ ‐$ 382.89$ 0.2% 0.2%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 383.58$ ‐$ 383.58$ ‐3.0% ‐3.0%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 320.50$ ‐$ 320.50$ ‐0.5% ‐0.5%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 316.99$ ‐$ 316.99$ ‐0.1% ‐0.1%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 242.54$ ‐$ 242.54$ 1.0% 1.0%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 511.05$ ‐$ 511.05$ 0.6% 0.6%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 488.57$ ‐$ 488.57$ 0.6% 0.6%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 399.49$ ‐$ 399.49$ 0.1% 0.1%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 399.39$ ‐$ 399.39$ ‐3.0% ‐3.0%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 335.20$ ‐$ 335.20$ ‐0.4% ‐0.4%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 331.01$ ‐$ 331.01$ ‐0.1% ‐0.1%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 252.67$ ‐$ 252.67$ 0.9% 0.9%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 308.05$ ‐$ 308.05$ 0.2% 0.2%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 391.40$ ‐$ 391.40$ ‐0.4% ‐0.4%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 299.88$ ‐$ 299.88$ ‐0.5% ‐0.5%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 411.26$ ‐$ 411.26$ 0.3% 0.3%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 341.50$ ‐$ 341.50$ 0.3% 0.3%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 319.90$ ‐$ 319.90$ 0.2% 0.2%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 347.81$ ‐$ 347.81$ 1.6% 1.6%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 264.44$ ‐$ 264.44$ 1.3% 1.3%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 391.40$ ‐$ 391.40$ ‐0.4% ‐0.4%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 314.39$ ‐$ 314.39$ 0.6% 0.6%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 299.88$ ‐$ 299.88$ ‐0.5% ‐0.5%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 441.04$ ‐$ 441.04$ 0.9% 0.9%‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$

Quarter 1 2019, 21‐year‐old Non‐Tobacco Premium PMPM Change in Quarter 1, 21‐year‐old Non‐Tobacco Premium PMPM

1 2 3 4 5 6 7 8 9

Average (weighted

by enrollment by rating area) 1 2 3 4 5 6 7 8 9

Average (weighted


‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 368.84$ ‐$ 368.84$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 378.06$ ‐$ 378.06$

‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 501.18$ ‐$ 501.18$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 513.71$ ‐$ 513.71$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 479.14$ ‐$ 479.14$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 491.12$ ‐$ 491.12$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 392.46$ ‐$ 392.46$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 402.27$ ‐$ 402.27$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 393.17$ ‐$ 393.17$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 403.00$ ‐$ 403.00$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 324.92$ ‐$ 324.92$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 333.04$ ‐$ 333.04$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 248.61$ ‐$ 248.61$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 254.82$ ‐$ 254.82$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 356.50$ ‐$ 356.50$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 365.41$ ‐$ 365.41$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 271.05$ ‐$ 271.05$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 277.83$ ‐$ 277.83$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 409.47$ ‐$ 409.47$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 419.71$ ‐$ 419.71$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 409.37$ ‐$ 409.37$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 419.60$ ‐$ 419.60$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 343.58$ ‐$ 343.58$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 352.17$ ‐$ 352.17$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 258.98$ ‐$ 258.98$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 265.46$ ‐$ 265.46$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 404.34$ ‐$ 404.34$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 414.45$ ‐$ 414.45$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 501.18$ ‐$ 501.18$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 513.71$ ‐$ 513.71$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 479.14$ ‐$ 479.14$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 491.12$ ‐$ 491.12$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 392.46$ ‐$ 392.46$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 402.27$ ‐$ 402.27$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 393.17$ ‐$ 393.17$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 403.00$ ‐$ 403.00$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 328.51$ ‐$ 328.51$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 336.73$ ‐$ 336.73$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 324.92$ ‐$ 324.92$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 333.04$ ‐$ 333.04$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 248.61$ ‐$ 248.61$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 254.82$ ‐$ 254.82$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 523.83$ ‐$ 523.83$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 536.92$ ‐$ 536.92$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 500.79$ ‐$ 500.79$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 513.31$ ‐$ 513.31$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 409.47$ ‐$ 409.47$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 419.71$ ‐$ 419.71$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 409.37$ ‐$ 409.37$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 419.60$ ‐$ 419.60$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 343.58$ ‐$ 343.58$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 352.17$ ‐$ 352.17$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 339.28$ ‐$ 339.28$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 347.77$ ‐$ 347.77$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 258.98$ ‐$ 258.98$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 265.46$ ‐$ 265.46$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 315.75$ ‐$ 315.75$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 323.64$ ‐$ 323.64$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 401.18$ ‐$ 401.18$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 411.21$ ‐$ 411.21$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 307.38$ ‐$ 307.38$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 315.06$ ‐$ 315.06$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 421.54$ ‐$ 421.54$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 432.08$ ‐$ 432.08$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 350.04$ ‐$ 350.04$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 358.79$ ‐$ 358.79$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 327.89$ ‐$ 327.89$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 336.09$ ‐$ 336.09$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 356.50$ ‐$ 356.50$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 365.41$ ‐$ 365.41$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 271.05$ ‐$ 271.05$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 277.83$ ‐$ 277.83$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 401.18$ ‐$ 401.18$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 411.21$ ‐$ 411.21$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 322.25$ ‐$ 322.25$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 330.31$ ‐$ 330.31$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 307.38$ ‐$ 307.38$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 315.06$ ‐$ 315.06$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 452.06$ ‐$ 452.06$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 463.36$ ‐$ 463.36$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$

Quarter 3 2019, 21‐year‐old Non‐Tobacco Premium PMPMQuarter 2 2019, 21‐year‐old Non‐Tobacco Premium PMPM

1 2 3 4 5 6 7 8 9

Average (weighted


‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 387.51$ ‐$ 387.51$

‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 526.55$ ‐$ 526.55$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 503.40$ ‐$ 503.40$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 412.32$ ‐$ 412.32$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 413.07$ ‐$ 413.07$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 341.36$ ‐$ 341.36$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 261.19$ ‐$ 261.19$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 374.55$ ‐$ 374.55$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 284.78$ ‐$ 284.78$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 430.20$ ‐$ 430.20$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 430.09$ ‐$ 430.09$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 360.97$ ‐$ 360.97$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 272.09$ ‐$ 272.09$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 424.81$ ‐$ 424.81$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 526.55$ ‐$ 526.55$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 503.40$ ‐$ 503.40$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 412.32$ ‐$ 412.32$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 413.07$ ‐$ 413.07$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 345.14$ ‐$ 345.14$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 341.36$ ‐$ 341.36$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 261.19$ ‐$ 261.19$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 550.34$ ‐$ 550.34$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 526.14$ ‐$ 526.14$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 430.20$ ‐$ 430.20$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 430.09$ ‐$ 430.09$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 360.97$ ‐$ 360.97$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 356.46$ ‐$ 356.46$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 272.09$ ‐$ 272.09$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 331.73$ ‐$ 331.73$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 421.49$ ‐$ 421.49$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 322.94$ ‐$ 322.94$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 442.88$ ‐$ 442.88$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 367.76$ ‐$ 367.76$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 344.49$ ‐$ 344.49$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 374.55$ ‐$ 374.55$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 284.78$ ‐$ 284.78$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 421.49$ ‐$ 421.49$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 338.56$ ‐$ 338.56$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 322.94$ ‐$ 322.94$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ 474.95$ ‐$ 474.95$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$ ‐$

Quarter 4 2019, 21‐year‐old Non‐Tobacco Premium PMPM

PA Rate Quarterly Template Part VConsumer Factors

Carrier Name: KHPE Insurance Company, Inc.

Product(s): HMO

Market Segment: Small Group

Rate Effective Date: 1/1/2019

Table 12. Age and Tobacco Factors Table 13. Geographic Factors

Age Band

Age Factor

Tobacco Factor

Age Band

Age Factor

Tobacco Factor

Area CountiesCurrent Factor

Proposed Factor

0‐14 0.765 40 1.278 1.225 Rating Area 115 0.833 41 1.302 1.225 Rating Area 2 16 0.859 42 1.325 1.225 Rating Area 317 0.885 43 1.357 1.225 Rating Area 4 18 0.913 1.000 44 1.397 1.225 Rating Area 519 0.941 1.000 45 1.444 1.225 Rating Area 620 0.970 1.000 46 1.500 1.225 Rating Area 7

21 1.000 1.125 47 1.563 1.225 Rating Area 8Bucks, Chester, Delaware, Philadelphia, Montgomery

1.000 1.000

22 1.000 1.125 48 1.635 1.225 Rating Area 923 1.000 1.125 49 1.706 1.22524 1.000 1.125 50 1.786 1.375

25 1.004 1.125 51 1.865 1.375 Table 14. Network Factors26 1.024 1.125 52 1.952 1.37527 1.048 1.125 53 2.040 1.375

28 1.087 1.125 54 2.135 1.375 Network Name Rating AreaCurrent Factor

Proposed Factor

DOH Approval Date

29 1.119 1.125 55 2.230 1.375 Proactive Rating Area 8 1.000 1.00030 1.135 1.175 56 2.333 1.375 Keystone Rating Area 8 1.100 1.10031 1.159 1.175 57 2.437 1.37532 1.183 1.175 58 2.548 1.37533 1.198 1.175 59 2.603 1.37534 1.214 1.175 60 2.714 1.37535 1.222 1.175 61 2.810 1.37536 1.230 1.175 62 2.873 1.37537 1.238 1.175 63 2.952 1.37538 1.246 1.175 64+ 3.000 1.37539 1.262 1.175

*PA follows the federal default age curve.

Projection Period Age and Tobacco Factors Geographic Area Factors

Projecion Period Network Factors

Rate Pages

Company Name:Market:Product:

Effective Date of Rates: Ending date of Rates:

HIOS Plan ID (On Exchange)=>HIOS Plan ID (Off Exchange)=>

Plan Marketing Name =>Form # =>

Rating Area =>Network =>Metal =>

Deductible =>Coinsurance =>

Copays =>OOP Maximum =>

Pediatric Dental (Yes/No) =>Age Band Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco

0‐14 $374.05 $374.05 $357.60 $357.60 $292.91 $292.91 $293.44 $293.4415 $407.30 $407.30 $389.39 $389.39 $318.94 $318.94 $319.52 $319.5216 $420.02 $420.02 $401.55 $401.55 $328.90 $328.90 $329.49 $329.4917 $432.73 $432.73 $413.70 $413.70 $338.85 $338.85 $339.47 $339.4718 $446.42 $446.42 $426.79 $426.79 $349.57 $349.57 $350.21 $350.2119 $460.11 $460.11 $439.88 $439.88 $360.30 $360.30 $360.95 $360.9520 $474.29 $474.29 $453.43 $453.43 $371.40 $371.40 $372.07 $372.0721 $488.96 $550.08 $467.46 $525.89 $382.89 $430.75 $383.58 $431.5322 $488.96 $550.08 $467.46 $525.89 $382.89 $430.75 $383.58 $431.5323 $488.96 $550.08 $467.46 $525.89 $382.89 $430.75 $383.58 $431.5324 $488.96 $550.08 $467.46 $525.89 $382.89 $430.75 $383.58 $431.5325 $490.92 $552.28 $469.33 $527.99 $384.42 $432.47 $385.11 $433.2526 $500.70 $563.28 $478.68 $538.51 $392.07 $441.08 $392.78 $441.8827 $512.43 $576.48 $489.89 $551.13 $401.26 $451.42 $401.99 $452.2428 $531.50 $597.94 $508.13 $571.64 $416.20 $468.22 $416.95 $469.0729 $547.15 $615.54 $523.08 $588.47 $428.45 $482.01 $429.22 $482.8830 $554.97 $652.09 $530.56 $623.41 $434.58 $510.63 $435.36 $511.5531 $566.70 $665.88 $541.78 $636.59 $443.76 $521.42 $444.57 $522.3732 $578.44 $679.67 $553.00 $649.78 $452.95 $532.22 $453.77 $533.1833 $585.77 $688.28 $560.01 $658.02 $458.70 $538.97 $459.53 $539.9434 $593.60 $697.48 $567.49 $666.80 $464.82 $546.17 $465.66 $547.1635 $597.51 $702.07 $571.23 $671.20 $467.89 $549.77 $468.73 $550.7636 $601.42 $706.67 $574.97 $675.59 $470.95 $553.37 $471.80 $554.3737 $605.33 $711.27 $578.71 $679.99 $474.01 $556.96 $474.87 $557.9738 $609.24 $715.86 $582.45 $684.38 $477.08 $560.56 $477.94 $561.5839 $617.07 $725.05 $589.93 $693.17 $483.20 $567.76 $484.08 $568.7940 $624.89 $765.49 $597.41 $731.83 $489.33 $599.43 $490.21 $600.5141 $636.63 $779.87 $608.63 $745.57 $498.52 $610.68 $499.42 $611.7942 $647.87 $793.64 $619.38 $758.74 $507.32 $621.47 $508.24 $622.6043 $663.52 $812.81 $634.34 $777.07 $519.58 $636.48 $520.52 $637.6344 $683.08 $836.77 $653.04 $799.97 $534.89 $655.24 $535.86 $656.4345 $706.06 $864.92 $675.01 $826.88 $552.89 $677.29 $553.89 $678.5146 $733.44 $898.46 $701.19 $858.95 $574.33 $703.55 $575.37 $704.8347 $764.24 $936.20 $730.64 $895.03 $598.45 $733.10 $599.53 $734.4348 $799.45 $979.33 $764.29 $936.26 $626.02 $766.87 $627.15 $768.2649 $834.17 $1,021.85 $797.48 $976.91 $653.20 $800.17 $654.39 $801.6250 $873.28 $1,200.76 $834.88 $1,147.96 $683.83 $940.27 $685.07 $941.9751 $911.91 $1,253.88 $871.81 $1,198.73 $714.08 $981.86 $715.37 $983.6452 $954.45 $1,312.37 $912.48 $1,254.65 $747.39 $1,027.67 $748.75 $1,029.5353 $997.48 $1,371.53 $953.61 $1,311.22 $781.09 $1,073.99 $782.50 $1,075.9454 $1,043.93 $1,435.40 $998.02 $1,372.28 $817.46 $1,124.01 $818.94 $1,126.0455 $1,090.38 $1,499.27 $1,042.43 $1,433.34 $853.84 $1,174.02 $855.38 $1,176.1556 $1,140.74 $1,568.52 $1,090.58 $1,499.54 $893.27 $1,228.25 $894.89 $1,230.4757 $1,191.60 $1,638.44 $1,139.19 $1,566.39 $933.09 $1,283.00 $934.78 $1,285.3258 $1,245.87 $1,713.07 $1,191.08 $1,637.74 $975.59 $1,341.44 $977.36 $1,343.8759 $1,272.76 $1,750.05 $1,216.79 $1,673.09 $996.65 $1,370.40 $998.46 $1,372.8860 $1,327.04 $1,824.68 $1,268.68 $1,744.43 $1,039.15 $1,428.83 $1,041.03 $1,431.4261 $1,373.98 $1,889.22 $1,313.55 $1,806.14 $1,075.91 $1,479.37 $1,077.86 $1,482.0562 $1,404.78 $1,931.58 $1,343.00 $1,846.63 $1,100.03 $1,512.54 $1,102.02 $1,515.2863 $1,443.41 $1,984.69 $1,379.93 $1,897.41 $1,130.28 $1,554.13 $1,132.32 $1,556.9564+ $1,466.88 $2,016.96 $1,402.37 $1,928.26 $1,148.66 $1,579.40 $1,150.74 $1,582.26

$6,000

Keystone HMO Gold Classic $1,500/$25/$50/90%

$1,50010%

Yes

Keystone HMO Platinum Preferred $10/$20/$150

Keystone Health Plan East Network Platinum

8

$10/$20

00%

$4,000

KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19KE 670 WPR GMC Rev. 1.19

$4,500

Keystone Health Plan East Network Gold

$25 no ded/$50 no ded

GoldPlatinumKeystone Health Plan East Network Keystone Health Plan East Network

Yes

KE 670 WPR GMC Rev. 1.198

$00%

$35/$70$7,900

88

YesYes

$20/$400%$0

Keystone Health Plan EastSmall Group

HMOJanuary 1, 2019

33871PA0100021

March 31, 2019

33871PA010002333871PA0100020 33871PA0100022Keystone HMO Gold Preferred $35/$70/$650Keystone HMO Platinum Preferred $20/$40/$200

INAC‐131478481KHPE Small Group

State Rate TemplateMay 21, 2018

Rate Pages


Effective Date of Rates:






Pediatric Dental (Yes/No) =>Age Band

0‐141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364+

Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$245.18 $245.18 $242.50 $242.50 $185.54 $185.54 $266.07 $266.07$266.98 $266.98 $264.05 $264.05 $202.04 $202.04 $289.72 $289.72$275.31 $275.31 $272.30 $272.30 $208.34 $208.34 $298.77 $298.77$283.64 $283.64 $280.54 $280.54 $214.65 $214.65 $307.81 $307.81$292.62 $292.62 $289.41 $289.41 $221.44 $221.44 $317.55 $317.55$301.59 $301.59 $298.29 $298.29 $228.23 $228.23 $327.29 $327.29$310.89 $310.89 $307.48 $307.48 $235.27 $235.27 $337.37 $337.37$320.50 $360.57 $316.99 $356.61 $242.54 $272.86 $347.81 $391.28$320.50 $360.57 $316.99 $356.61 $242.54 $272.86 $347.81 $391.28$320.50 $360.57 $316.99 $356.61 $242.54 $272.86 $347.81 $391.28$320.50 $360.57 $316.99 $356.61 $242.54 $272.86 $347.81 $391.28$321.78 $362.01 $318.26 $358.04 $243.51 $273.95 $349.20 $392.85$328.19 $369.22 $324.60 $365.17 $248.36 $279.41 $356.15 $400.67$335.89 $377.87 $332.21 $373.73 $254.18 $285.96 $364.50 $410.06$348.39 $391.93 $344.57 $387.64 $263.64 $296.60 $378.07 $425.32$358.64 $403.47 $354.71 $399.05 $271.40 $305.33 $389.20 $437.85$363.77 $427.43 $359.78 $422.75 $275.28 $323.46 $394.76 $463.84$371.46 $436.47 $367.39 $431.69 $281.11 $330.30 $403.11 $473.65$379.15 $445.51 $375.00 $440.63 $286.93 $337.14 $411.46 $483.46$383.96 $451.15 $379.76 $446.21 $290.57 $341.41 $416.67 $489.59$389.09 $457.18 $384.83 $452.17 $294.45 $345.97 $422.24 $496.13$391.65 $460.19 $387.36 $455.15 $296.39 $348.25 $425.02 $499.40$394.22 $463.21 $389.90 $458.13 $298.33 $350.53 $427.80 $502.67$396.78 $466.22 $392.43 $461.11 $300.27 $352.81 $430.59 $505.94$399.35 $469.23 $394.97 $464.09 $302.21 $355.09 $433.37 $509.21$404.47 $475.26 $400.04 $470.05 $306.09 $359.65 $438.93 $515.75$409.60 $501.76 $405.11 $496.26 $309.97 $379.71 $444.50 $544.51$417.29 $511.19 $412.72 $505.58 $315.79 $386.84 $452.85 $554.74$424.67 $520.22 $420.01 $514.52 $321.37 $393.68 $460.84 $564.53$434.92 $532.78 $430.16 $526.94 $329.13 $403.18 $471.97 $578.17$447.74 $548.48 $442.84 $542.47 $338.83 $415.07 $485.89 $595.21$462.81 $566.94 $457.73 $560.73 $350.23 $429.03 $502.23 $615.24$480.75 $588.92 $475.49 $582.47 $363.81 $445.67 $521.71 $639.10$500.95 $613.66 $495.46 $606.93 $379.09 $464.39 $543.62 $665.94$524.02 $641.93 $518.28 $634.89 $396.56 $485.78 $568.66 $696.61$546.78 $669.80 $540.79 $662.46 $413.78 $506.88 $593.36 $726.87$572.42 $787.07 $566.15 $778.45 $433.18 $595.62 $621.18 $854.13$597.74 $821.89 $591.19 $812.88 $452.34 $621.97 $648.66 $891.91$625.62 $860.23 $618.77 $850.80 $473.44 $650.98 $678.92 $933.51$653.82 $899.01 $646.66 $889.16 $494.79 $680.33 $709.53 $975.60$684.27 $940.87 $676.78 $930.57 $517.83 $712.01 $742.57 $1,021.03$714.72 $982.74 $706.89 $971.97 $540.87 $743.69 $775.61 $1,066.46$747.73 $1,028.13 $739.54 $1,016.87 $565.85 $778.04 $811.43 $1,115.72$781.06 $1,073.96 $772.51 $1,062.20 $591.07 $812.73 $847.61 $1,165.46$816.64 $1,122.88 $807.69 $1,110.58 $618.00 $849.75 $886.21 $1,218.54$834.27 $1,147.12 $825.13 $1,134.55 $631.34 $868.09 $905.34 $1,244.85$869.84 $1,196.03 $860.31 $1,182.93 $658.26 $905.11 $943.95 $1,297.93$900.61 $1,238.34 $890.74 $1,224.77 $681.54 $937.12 $977.34 $1,343.84$920.80 $1,266.10 $910.71 $1,252.23 $696.82 $958.13 $999.25 $1,373.97$946.12 $1,300.92 $935.76 $1,286.67 $715.98 $984.48 $1,026.73 $1,411.75$961.50 $1,322.07 $950.97 $1,307.59 $727.62 $1,000.48 $1,043.42 $1,434.71

$4,25030%

$25 no ded/$50 no ded$7,900Yes

Keystone Health Plan East Network Silver

33871PA0100024Keystone HMO Silver Classic $4,250/$25/$50/70%


33871PA0100025 33871PA0100026 33871PA0100044Keystone HMO Gold ProactiveKeystone HMO Silver Classic $3,250/$30/$60/50% Keystone HMO Bronze Essential $6,850/$50/$100/$700

KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.1988 8

Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network GoldSilver Bronze

$3,250 $6,850 $00%/20%/30%50% 50%

$30 no ded/$60 no ded $50 no ded/$100 no ded $15/$40, $30/$60, $45/$80$7,900Yes

$7,900 $7,900Yes Yes



Rate Pages









0‐141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364+

Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$202.30 $202.30 $299.42 $299.42 $240.51 $240.51 $229.41 $229.41$220.28 $220.28 $326.03 $326.03 $261.89 $261.89 $249.80 $249.80$227.16 $227.16 $336.21 $336.21 $270.06 $270.06 $257.60 $257.60$234.03 $234.03 $346.39 $346.39 $278.24 $278.24 $265.40 $265.40$241.44 $241.44 $357.35 $357.35 $287.04 $287.04 $273.79 $273.79$248.84 $248.84 $368.30 $368.30 $295.84 $295.84 $282.19 $282.19$256.51 $256.51 $379.66 $379.66 $304.96 $304.96 $290.89 $290.89$264.44 $297.50 $391.40 $440.32 $314.39 $353.69 $299.88 $337.37$264.44 $297.50 $391.40 $440.32 $314.39 $353.69 $299.88 $337.37$264.44 $297.50 $391.40 $440.32 $314.39 $353.69 $299.88 $337.37$264.44 $297.50 $391.40 $440.32 $314.39 $353.69 $299.88 $337.37$265.50 $298.69 $392.96 $442.08 $315.65 $355.10 $301.08 $338.72$270.79 $304.64 $400.79 $450.89 $321.94 $362.18 $307.08 $345.46$277.14 $311.78 $410.18 $461.46 $329.48 $370.67 $314.28 $353.56$287.45 $323.38 $425.45 $478.63 $341.74 $384.46 $325.97 $366.72$295.91 $332.90 $437.97 $492.72 $351.80 $395.78 $335.57 $377.51$300.14 $352.67 $444.24 $521.98 $356.83 $419.28 $340.37 $399.93$306.49 $360.13 $453.63 $533.01 $364.38 $428.14 $347.56 $408.39$312.84 $367.58 $463.02 $544.05 $371.92 $437.01 $354.76 $416.84$316.80 $372.24 $468.89 $550.95 $376.64 $442.55 $359.26 $422.13$321.03 $377.21 $475.16 $558.31 $381.67 $448.46 $364.06 $427.77$323.15 $379.70 $478.29 $561.99 $384.19 $451.42 $366.46 $430.58$325.26 $382.19 $481.42 $565.67 $386.70 $454.37 $368.85 $433.40$327.38 $384.67 $484.55 $569.35 $389.22 $457.33 $371.25 $436.22$329.50 $387.16 $487.68 $573.03 $391.73 $460.28 $373.65 $439.04$333.73 $392.13 $493.94 $580.38 $396.76 $466.19 $378.45 $444.68$337.96 $414.00 $500.21 $612.75 $401.79 $492.19 $383.25 $469.48$344.30 $421.77 $509.60 $624.26 $409.34 $501.44 $390.45 $478.30$350.39 $429.22 $518.60 $635.29 $416.57 $510.29 $397.34 $486.75$358.85 $439.59 $531.13 $650.63 $426.63 $522.62 $406.94 $498.50$369.43 $452.55 $546.78 $669.81 $439.20 $538.02 $418.93 $513.19$381.86 $467.77 $565.18 $692.34 $453.98 $556.13 $433.03 $530.46$396.66 $485.91 $587.10 $719.19 $471.59 $577.69 $449.82 $551.03$413.32 $506.32 $611.75 $749.40 $491.39 $601.96 $468.71 $574.18$432.36 $529.65 $639.93 $783.92 $514.03 $629.68 $490.31 $600.63$451.14 $552.65 $667.72 $817.96 $536.35 $657.03 $511.60 $626.71$472.30 $649.41 $699.04 $961.17 $561.50 $772.06 $535.59 $736.43$493.19 $678.13 $729.96 $1,003.69 $586.34 $806.21 $559.28 $769.01$516.19 $709.77 $764.01 $1,050.51 $613.69 $843.82 $585.37 $804.88$539.46 $741.76 $798.45 $1,097.87 $641.36 $881.86 $611.76 $841.17$564.59 $776.31 $835.63 $1,149.00 $671.22 $922.93 $640.25 $880.34$589.71 $810.85 $872.82 $1,200.12 $701.09 $964.00 $668.74 $919.51$616.95 $848.30 $913.13 $1,255.55 $733.47 $1,008.53 $699.62 $961.98$644.45 $886.12 $953.84 $1,311.52 $766.17 $1,053.48 $730.81 $1,004.87$673.80 $926.48 $997.28 $1,371.26 $801.07 $1,101.47 $764.10 $1,050.63$688.35 $946.47 $1,018.81 $1,400.86 $818.36 $1,125.24 $780.59 $1,073.31$717.70 $986.84 $1,062.25 $1,460.60 $853.26 $1,173.23 $813.88 $1,119.08$743.08 $1,021.74 $1,099.83 $1,512.26 $883.44 $1,214.73 $842.67 $1,158.67$759.74 $1,044.65 $1,124.48 $1,546.17 $903.24 $1,241.96 $861.56 $1,184.64$780.64 $1,073.37 $1,155.41 $1,588.68 $928.08 $1,276.11 $885.25 $1,217.22$793.32 $1,090.83 $1,174.19 $1,614.51 $943.17 $1,296.86 $899.64 $1,237.01

33871PA0100045 33871PA0100047 33871PA010004933871PA0100048Keystone HMO Silver Proactive Keystone HMO Gold Classic $2,500/$40/$80/100% Keystone HMO Silver Secure $5,000/$40/$80/$600Keystone HMO Silver Classic $4,500/$40/$80/100%KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19KE 670 WPR GMC Rev. 1.19

8 8 88Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network

Silver Gold SilverSilver$0/$6000/$6000 $2,500 $5,000$4,5000%/5%/10% 0% 0%0%

$40/$80, $60 no ded/$120 no ded, $70 no ded/$140 no ded $40 no ded/$80 no ded $40 no ded/$80 no ded$40 no ded/$80 no ded$7,900 $4,000 $7,900$7,900Yes Yes YesYes



Rate Pages









0‐141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364+

Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$337.39 $337.39 $390.95 $390.95 $373.76 $373.76 $305.61 $305.61$367.38 $367.38 $425.71 $425.71 $406.98 $406.98 $332.77 $332.77$378.85 $378.85 $438.99 $438.99 $419.69 $419.69 $343.16 $343.16$390.32 $390.32 $452.28 $452.28 $432.39 $432.39 $353.54 $353.54$402.67 $402.67 $466.59 $466.59 $446.07 $446.07 $364.73 $364.73$415.01 $415.01 $480.90 $480.90 $459.75 $459.75 $375.92 $375.92$427.80 $427.80 $495.72 $495.72 $473.92 $473.92 $387.50 $387.50$441.04 $496.16 $511.05 $574.93 $488.57 $549.65 $399.49 $449.42$441.04 $496.16 $511.05 $574.93 $488.57 $549.65 $399.49 $449.42$441.04 $496.16 $511.05 $574.93 $488.57 $549.65 $399.49 $449.42$441.04 $496.16 $511.05 $574.93 $488.57 $549.65 $399.49 $449.42$442.80 $498.15 $513.10 $577.23 $490.53 $551.84 $401.08 $451.22$451.62 $508.07 $523.32 $588.73 $500.30 $562.84 $409.07 $460.21$462.20 $519.98 $535.58 $602.53 $512.03 $576.03 $418.66 $470.99$479.41 $539.33 $555.51 $624.95 $531.08 $597.47 $434.24 $488.52$493.52 $555.21 $571.87 $643.35 $546.71 $615.05 $447.02 $502.90$500.57 $588.18 $580.04 $681.55 $554.53 $651.57 $453.42 $532.76$511.16 $600.61 $592.31 $695.96 $566.26 $665.35 $463.00 $544.03$521.74 $613.05 $604.57 $710.37 $577.98 $679.13 $472.59 $555.30$528.36 $620.82 $612.24 $719.38 $585.31 $687.74 $478.58 $562.34$535.42 $629.11 $620.42 $728.99 $593.13 $696.93 $484.98 $569.85$538.94 $633.26 $624.50 $733.79 $597.04 $701.52 $488.17 $573.60$542.47 $637.41 $628.59 $738.60 $600.95 $706.11 $491.37 $577.36$546.00 $641.55 $632.68 $743.40 $604.86 $710.70 $494.56 $581.11$549.53 $645.70 $636.77 $748.20 $608.76 $715.30 $497.76 $584.87$556.59 $653.99 $644.95 $757.81 $616.58 $724.48 $504.15 $592.38$563.64 $690.46 $653.12 $800.08 $624.40 $764.89 $510.54 $625.41$574.23 $703.43 $665.39 $815.10 $636.12 $779.25 $520.13 $637.16$584.37 $715.86 $677.14 $829.50 $647.36 $793.02 $529.32 $648.42$598.48 $733.14 $693.50 $849.53 $663.00 $812.17 $542.10 $664.08$616.13 $754.75 $713.94 $874.57 $682.54 $836.11 $558.08 $683.65$636.85 $780.15 $737.96 $904.00 $705.50 $864.24 $576.86 $706.65$661.55 $810.40 $766.58 $939.06 $732.86 $897.76 $599.23 $734.06$689.34 $844.44 $798.77 $978.50 $763.64 $935.46 $624.40 $764.89$721.09 $883.34 $835.57 $1,023.57 $798.82 $978.55 $653.16 $800.12$752.41 $921.70 $871.85 $1,068.02 $833.51 $1,021.05 $681.52 $834.87$787.69 $1,083.07 $912.74 $1,255.01 $872.59 $1,199.82 $713.48 $981.04$822.53 $1,130.98 $953.11 $1,310.53 $911.19 $1,252.89 $745.04 $1,024.43$860.90 $1,183.74 $997.57 $1,371.66 $953.70 $1,311.33 $779.80 $1,072.22$899.71 $1,237.10 $1,042.54 $1,433.50 $996.69 $1,370.45 $814.95 $1,120.56$941.61 $1,294.71 $1,091.09 $1,500.25 $1,043.11 $1,434.27 $852.90 $1,172.74$983.51 $1,352.32 $1,139.64 $1,567.01 $1,089.52 $1,498.09 $890.85 $1,224.92

$1,028.94 $1,414.79 $1,192.28 $1,639.39 $1,139.84 $1,567.29 $932.00 $1,281.50$1,074.80 $1,477.85 $1,245.43 $1,712.47 $1,190.66 $1,637.15 $973.55 $1,338.63$1,123.76 $1,545.17 $1,302.16 $1,790.47 $1,244.89 $1,711.72 $1,017.89 $1,399.60$1,148.01 $1,578.52 $1,330.27 $1,829.12 $1,271.76 $1,748.67 $1,039.86 $1,429.81$1,196.97 $1,645.83 $1,386.99 $1,907.11 $1,325.99 $1,823.24 $1,084.20 $1,490.78$1,239.31 $1,704.05 $1,436.05 $1,974.57 $1,372.89 $1,887.73 $1,122.55 $1,543.51$1,267.09 $1,742.25 $1,468.25 $2,018.84 $1,403.67 $1,930.05 $1,147.72 $1,578.12$1,301.94 $1,790.16 $1,508.62 $2,074.36 $1,442.27 $1,983.12 $1,179.28 $1,621.51$1,323.11 $1,819.27 $1,533.15 $2,108.09 $1,465.71 $2,015.37 $1,198.46 $1,647.88

33871PA0110011 33871PA0110012 33871PA011001333871PA0100050Keystone HMO Platinum Preferred $30/$60/$400 Keystone DPOS Platinum Preferred $10/$20/$150 Keystone DPOS Platinum Preferred $20/$40/$200 Keystone DPOS Gold Preferred $35/$70/$650

KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19KE 670 WPR GMC Rev. 1.198 8 8 8

Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network Platinum Platinum Platinum Gold

$0 $0 $0$00% 0% 0% 0%

$10/$20 $20/$40 $35/$70$30/$60$5,000 $4,000 $4,500 $7,900

Yes Yes YesYes



Rate Pages









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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$305.53 $305.53 $256.43 $256.43 $253.22 $253.22 $193.29 $193.29$332.69 $332.69 $279.22 $279.22 $275.73 $275.73 $210.47 $210.47$343.07 $343.07 $287.94 $287.94 $284.34 $284.34 $217.04 $217.04$353.46 $353.46 $296.65 $296.65 $292.94 $292.94 $223.61 $223.61$364.64 $364.64 $306.04 $306.04 $302.21 $302.21 $230.69 $230.69$375.82 $375.82 $315.42 $315.42 $311.48 $311.48 $237.76 $237.76$387.40 $387.40 $325.14 $325.14 $321.08 $321.08 $245.09 $245.09$399.39 $449.31 $335.20 $377.10 $331.01 $372.39 $252.67 $284.25$399.39 $449.31 $335.20 $377.10 $331.01 $372.39 $252.67 $284.25$399.39 $449.31 $335.20 $377.10 $331.01 $372.39 $252.67 $284.25$399.39 $449.31 $335.20 $377.10 $331.01 $372.39 $252.67 $284.25$400.98 $451.11 $336.54 $378.61 $332.33 $373.88 $253.68 $285.39$408.97 $460.09 $343.25 $386.15 $338.95 $381.32 $258.73 $291.07$418.56 $470.88 $351.29 $395.20 $346.90 $390.26 $264.80 $297.89$434.13 $488.40 $364.36 $409.91 $359.81 $404.78 $274.65 $308.98$446.91 $502.78 $375.09 $421.98 $370.40 $416.70 $282.73 $318.08$453.30 $532.63 $380.45 $447.03 $375.70 $441.44 $286.78 $336.96$462.89 $543.89 $388.50 $456.48 $383.64 $450.78 $292.84 $344.09$472.47 $555.16 $396.54 $465.94 $391.58 $460.11 $298.91 $351.21$478.46 $562.19 $401.57 $471.84 $396.55 $465.95 $302.70 $355.67$484.85 $569.70 $406.93 $478.15 $401.85 $472.17 $306.74 $360.42$488.05 $573.46 $409.61 $481.30 $404.49 $475.28 $308.76 $362.79$491.24 $577.21 $412.30 $484.45 $407.14 $478.39 $310.78 $365.17$494.44 $580.97 $414.98 $487.60 $409.79 $481.50 $312.80 $367.54$497.63 $584.72 $417.66 $490.75 $412.44 $484.62 $314.82 $369.92$504.02 $592.23 $423.02 $497.05 $417.73 $490.84 $318.87 $374.67$510.41 $625.26 $428.39 $524.77 $423.03 $518.21 $322.91 $395.56$520.00 $637.00 $436.43 $534.63 $430.97 $527.94 $328.97 $402.99$529.19 $648.25 $444.14 $544.07 $438.59 $537.27 $334.78 $410.11$541.97 $663.91 $454.87 $557.21 $449.18 $550.25 $342.87 $420.02$557.94 $683.48 $468.27 $573.64 $462.42 $566.47 $352.98 $432.40$576.71 $706.47 $484.03 $592.94 $477.98 $585.52 $364.85 $446.94$599.08 $733.87 $502.80 $615.93 $496.51 $608.23 $379.00 $464.28$624.24 $764.69 $523.92 $641.80 $517.37 $633.78 $394.92 $483.78$653.00 $799.92 $548.05 $671.36 $541.20 $662.97 $413.11 $506.06$681.35 $834.66 $571.85 $700.52 $564.70 $691.76 $431.05 $528.04$713.30 $980.79 $598.67 $823.17 $591.18 $812.88 $451.26 $620.49$744.85 $1,024.17 $625.15 $859.58 $617.33 $848.83 $471.22 $647.93$779.60 $1,071.95 $654.31 $899.68 $646.13 $888.43 $493.21 $678.16$814.75 $1,120.28 $683.81 $940.24 $675.26 $928.48 $515.44 $708.73$852.69 $1,172.45 $715.65 $984.02 $706.71 $971.72 $539.44 $741.74$890.63 $1,224.62 $747.50 $1,027.81 $738.15 $1,014.96 $563.45 $774.74$931.77 $1,281.18 $782.02 $1,075.28 $772.25 $1,061.84 $589.47 $810.53$973.30 $1,338.29 $816.88 $1,123.21 $806.67 $1,109.17 $615.75 $846.66

$1,017.63 $1,399.25 $854.09 $1,174.37 $843.41 $1,159.69 $643.80 $885.22$1,039.60 $1,429.45 $872.53 $1,199.72 $861.62 $1,184.73 $657.69 $904.33$1,083.93 $1,490.41 $909.73 $1,250.88 $898.36 $1,235.25 $685.74 $942.89$1,122.27 $1,543.13 $941.91 $1,295.13 $930.14 $1,278.94 $710.00 $976.24$1,147.43 $1,577.72 $963.03 $1,324.17 $950.99 $1,307.61 $725.91 $998.13$1,178.99 $1,621.11 $989.51 $1,360.58 $977.14 $1,343.57 $745.87 $1,025.58$1,198.16 $1,647.46 $1,005.60 $1,382.70 $993.03 $1,365.42 $758.00 $1,042.25

33871PA0110014 33871PA0110016 33871PA0110019 33871PA0110020Keystone DPOS Gold Classic $1,500/$25/$50/90% Keystone DPOS Silver Classic $4,250/$25/$50/70% Keystone DPOS Silver Classic $3,250/$30/$60/50% Keystone DPOS Bronze Essential $6,850/$50/$100/$700

KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.198 8 8 8

Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network Gold Silver Silver Bronze$1,500 $4,250 $3,250 $6,85010% 30% 50% 50%

$25 no ded/$50 no ded $25 no ded/$50 no ded $30 no ded/$60 no ded $50 no ded/$100 no ded$6,000 $7,900 $7,900 $7,900Yes Yes Yes Yes



Plan Design Summary

HIOS Plan ID Plan Marketing Name Product MetalOn/Off Exchange Network Rating Area Counties Covered

33871PA0100020 Keystone HMO Platinum Preferred $10/$20/$150 HMO Platinum Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia


33871PA0100022 Keystone HMO Gold Preferred $35/$70/$650 HMO Gold Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia

33871PA0100023 Keystone HMO Gold Classic $1,500/$25/$50/90% HMO Gold Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia

33871PA0100024 Keystone HMO Silver Classic $4,250/$25/$50/70% HMO Silver Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia


33871PA0100026 Keystone HMO Bronze Essential $6,850/$50/$100/$700 HMO Bronze Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia

33871PA0100044 Keystone HMO Gold Proactive HMO Gold Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia

33871PA0100045 Keystone HMO Silver Proactive HMO Silver Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia



33871PA0100049 Keystone HMO Silver Secure $5,000/$40/$80/$600 HMO Silver Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia


33871PA0110011 Keystone DPOS Platinum Preferred $10/$20/$150 HMO Platinum Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia


33871PA0110013 Keystone DPOS Gold Preferred $35/$70/$650 HMO Gold Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia

33871PA0110014 Keystone DPOS Gold Classic $1,500/$25/$50/90% HMO Gold Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia

33871PA0110016 Keystone DPOS Silver Classic $4,250/$25/$50/70% HMO Silver Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia


33871PA0110020 Keystone DPOS Bronze Essential $6,850/$50/$100/$700 HMO Bronze Off Keystone Health P 8 Bucks, Chester, Delaware, Montgomery, Philadelphia


Plan Design Summary



Rates by County

Company Name Keystone Health Plan EastMarket Small GroupRATES FOR AGE 21, NON‐TOBACCO USER, BY RATING AREA AND COUNTY

RATING AREA 827,377 16,768 16,060 31,650 22,510

HIOS Plan ID Plan Marketing Name Product MetalOn/Off Exchange Bucks Chester Delaware Montgomery Philadelphia

33871PA0100020 Keystone HMO Platinum Preferred $10/$20/$150 HMO Platinum Off $488.96 $488.96 $488.96 $488.96 $488.9633871PA0100021 Keystone HMO Platinum Preferred $20/$40/$200 HMO Platinum Off $467.46 $467.46 $467.46 $467.46 $467.4633871PA0100022 Keystone HMO Gold Preferred $35/$70/$650 HMO Gold Off $382.89 $382.89 $382.89 $382.89 $382.8933871PA0100023 Keystone HMO Gold Classic $1,500/$25/$50/90% HMO Gold Off $383.58 $383.58 $383.58 $383.58 $383.5833871PA0100024 Keystone HMO Silver Classic $4,250/$25/$50/70% HMO Silver Off $320.50 $320.50 $320.50 $320.50 $320.5033871PA0100025 Keystone HMO Silver Classic $3,250/$30/$60/50% HMO Silver Off $316.99 $316.99 $316.99 $316.99 $316.9933871PA0100026 Keystone HMO Bronze Essential $6,850/$50/$100/$700 HMO Bronze Off $242.54 $242.54 $242.54 $242.54 $242.5433871PA0100044 Keystone HMO Gold Proactive HMO Gold Off $347.81 $347.81 $347.81 $347.81 $347.8133871PA0100045 Keystone HMO Silver Proactive HMO Silver Off $264.44 $264.44 $264.44 $264.44 $264.4433871PA0100047 Keystone HMO Gold Classic $2,500/$40/$80/100% HMO Gold Off $391.40 $391.40 $391.40 $391.40 $391.4033871PA0100048 Keystone HMO Silver Classic $4,500/$40/$80/100% HMO Silver Off $314.39 $314.39 $314.39 $314.39 $314.3933871PA0100049 Keystone HMO Silver Secure $5,000/$40/$80/$600 HMO Silver Off $299.88 $299.88 $299.88 $299.88 $299.8833871PA0100050 Keystone HMO Platinum Preferred $30/$60/$400 HMO Platinum Off $441.04 $441.04 $441.04 $441.04 $441.0433871PA0110011 Keystone DPOS Platinum Preferred $10/$20/$150 HMO Platinum Off $511.05 $511.05 $511.05 $511.05 $511.0533871PA0110012 Keystone DPOS Platinum Preferred $20/$40/$200 HMO Platinum Off $488.57 $488.57 $488.57 $488.57 $488.5733871PA0110013 Keystone DPOS Gold Preferred $35/$70/$650 HMO Gold Off $399.49 $399.49 $399.49 $399.49 $399.4933871PA0110014 Keystone DPOS Gold Classic $1,500/$25/$50/90% HMO Gold Off $399.39 $399.39 $399.39 $399.39 $399.3933871PA0110016 Keystone DPOS Silver Classic $4,250/$25/$50/70% HMO Silver Off $335.20 $335.20 $335.20 $335.20 $335.2033871PA0110019 Keystone DPOS Silver Classic $3,250/$30/$60/50% HMO Silver Off $331.01 $331.01 $331.01 $331.01 $331.0133871PA0110020 Keystone DPOS Bronze Essential $6,850/$50/$100/$700 HMO Bronze Off $252.67 $252.67 $252.67 $252.67 $252.67

02‐01‐2018 Number of Covered Lives by Rating County



Rate Pages









0‐14 $383.41 $383.41 $366.54 $366.54 $300.23 $300.23 $300.77 $300.7715 $417.49 $417.49 $399.13 $399.13 $326.92 $326.92 $327.51 $327.5116 $430.52 $430.52 $411.58 $411.58 $337.12 $337.12 $337.73 $337.7317 $443.55 $443.55 $424.04 $424.04 $347.32 $347.32 $347.95 $347.9518 $457.58 $457.58 $437.46 $437.46 $358.31 $358.31 $358.96 $358.9619 $471.61 $471.61 $450.87 $450.87 $369.30 $369.30 $369.97 $369.9720 $486.15 $486.15 $464.77 $464.77 $380.68 $380.68 $381.37 $381.3721 $501.18 $563.83 $479.14 $539.04 $392.46 $441.51 $393.17 $442.3122 $501.18 $563.83 $479.14 $539.04 $392.46 $441.51 $393.17 $442.3123 $501.18 $563.83 $479.14 $539.04 $392.46 $441.51 $393.17 $442.3124 $501.18 $563.83 $479.14 $539.04 $392.46 $441.51 $393.17 $442.3125 $503.19 $566.09 $481.06 $541.19 $394.03 $443.28 $394.74 $444.0826 $513.21 $577.36 $490.64 $551.97 $401.88 $452.11 $402.60 $452.9327 $525.24 $590.90 $502.14 $564.91 $411.30 $462.71 $412.04 $463.5428 $544.79 $612.88 $520.83 $585.93 $426.60 $479.93 $427.37 $480.8029 $560.82 $630.93 $536.16 $603.18 $439.16 $494.05 $439.95 $494.9530 $568.84 $668.39 $543.83 $639.00 $445.44 $523.39 $446.25 $524.3431 $580.87 $682.52 $555.33 $652.51 $454.86 $534.46 $455.68 $535.4332 $592.90 $696.66 $566.83 $666.02 $464.28 $545.53 $465.12 $546.5133 $600.42 $705.49 $574.01 $674.47 $470.16 $552.44 $471.02 $553.4434 $608.44 $714.91 $581.68 $683.47 $476.44 $559.82 $477.31 $560.8335 $612.45 $719.62 $585.51 $687.98 $479.58 $563.51 $480.45 $564.5336 $616.46 $724.34 $589.35 $692.48 $482.72 $567.20 $483.60 $568.2337 $620.47 $729.05 $593.18 $696.99 $485.86 $570.89 $486.74 $571.9238 $624.47 $733.76 $597.01 $701.49 $489.00 $574.58 $489.89 $575.6239 $632.49 $743.18 $604.68 $710.50 $495.28 $581.96 $496.18 $583.0140 $640.51 $784.63 $612.34 $750.12 $501.56 $614.41 $502.47 $615.5241 $652.54 $799.36 $623.84 $764.21 $510.98 $625.95 $511.90 $627.0842 $664.07 $813.48 $634.86 $777.71 $520.01 $637.01 $520.95 $638.1643 $680.11 $833.13 $650.20 $796.49 $532.56 $652.39 $533.53 $653.5744 $700.15 $857.69 $669.36 $819.97 $548.26 $671.62 $549.26 $672.8445 $723.71 $886.54 $691.88 $847.56 $566.71 $694.22 $567.73 $695.4746 $751.78 $920.92 $718.71 $880.42 $588.69 $721.14 $589.75 $722.4547 $783.35 $959.60 $748.90 $917.40 $613.41 $751.43 $614.52 $752.7948 $819.43 $1,003.81 $783.40 $959.66 $641.67 $786.04 $642.83 $787.4749 $855.02 $1,047.40 $817.42 $1,001.34 $669.53 $820.18 $670.74 $821.6650 $895.11 $1,230.78 $855.75 $1,176.65 $700.93 $963.78 $702.20 $965.5251 $934.71 $1,285.22 $893.60 $1,228.70 $731.93 $1,006.41 $733.26 $1,008.2352 $978.31 $1,345.18 $935.29 $1,286.02 $766.08 $1,053.36 $767.46 $1,055.2653 $1,022.41 $1,405.82 $977.45 $1,344.00 $800.61 $1,100.84 $802.06 $1,102.8454 $1,070.03 $1,471.29 $1,022.97 $1,406.58 $837.90 $1,152.11 $839.41 $1,154.1955 $1,117.64 $1,536.75 $1,068.49 $1,469.17 $875.18 $1,203.37 $876.76 $1,205.5556 $1,169.26 $1,607.73 $1,117.84 $1,537.03 $915.60 $1,258.95 $917.26 $1,261.2357 $1,221.38 $1,679.40 $1,167.67 $1,605.55 $956.42 $1,315.08 $958.15 $1,317.4658 $1,277.02 $1,755.90 $1,220.86 $1,678.68 $999.98 $1,374.97 $1,001.79 $1,377.4659 $1,304.58 $1,793.80 $1,247.21 $1,714.91 $1,021.57 $1,404.65 $1,023.42 $1,407.2060 $1,360.21 $1,870.29 $1,300.39 $1,788.04 $1,065.13 $1,464.55 $1,067.06 $1,467.2061 $1,408.33 $1,936.45 $1,346.39 $1,851.29 $1,102.81 $1,516.36 $1,104.80 $1,519.1062 $1,439.90 $1,979.86 $1,376.58 $1,892.79 $1,127.53 $1,550.35 $1,129.57 $1,553.1663 $1,479.49 $2,034.30 $1,414.43 $1,944.84 $1,158.53 $1,592.98 $1,160.63 $1,595.8764+ $1,503.54 $2,067.38 $1,437.42 $1,976.46 $1,177.37 $1,618.89 $1,179.50 $1,621.82

$6,000


$1,50010%

Yes



8

$10/$20

00%

$4,000


$4,500




Yes


$00%

$35/$70$7,900

88

YesYes

$20/$400%$0


HMOApril 1, 2019

33871PA0100021

June 30, 2019




Rate Pages









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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$251.31 $251.31 $248.56 $248.56 $190.18 $190.18 $272.72 $272.72$273.65 $273.65 $270.65 $270.65 $207.09 $207.09 $296.97 $296.97$282.19 $282.19 $279.10 $279.10 $213.55 $213.55 $306.24 $306.24$290.74 $290.74 $287.55 $287.55 $220.02 $220.02 $315.50 $315.50$299.93 $299.93 $296.65 $296.65 $226.98 $226.98 $325.49 $325.49$309.13 $309.13 $305.75 $305.75 $233.94 $233.94 $335.47 $335.47$318.66 $318.66 $315.17 $315.17 $241.15 $241.15 $345.81 $345.81$328.51 $369.58 $324.92 $365.53 $248.61 $279.68 $356.50 $401.06$328.51 $369.58 $324.92 $365.53 $248.61 $279.68 $356.50 $401.06$328.51 $369.58 $324.92 $365.53 $248.61 $279.68 $356.50 $401.06$328.51 $369.58 $324.92 $365.53 $248.61 $279.68 $356.50 $401.06$329.83 $371.06 $326.21 $366.99 $249.60 $280.80 $357.93 $402.67$336.40 $378.45 $332.71 $374.30 $254.57 $286.39 $365.06 $410.69$344.28 $387.32 $340.51 $383.08 $260.54 $293.11 $373.61 $420.32$357.10 $401.73 $353.18 $397.33 $270.23 $304.01 $387.52 $435.96$367.61 $413.56 $363.58 $409.03 $278.19 $312.96 $398.93 $448.79$372.86 $438.12 $368.78 $433.32 $282.17 $331.55 $404.63 $475.44$380.75 $447.38 $376.58 $442.48 $288.13 $338.56 $413.19 $485.49$388.63 $456.64 $384.37 $451.64 $294.10 $345.57 $421.74 $495.55$393.56 $462.43 $389.25 $457.37 $297.83 $349.95 $427.09 $501.83$398.82 $468.61 $394.45 $463.48 $301.81 $354.62 $432.79 $508.53$401.44 $471.70 $397.05 $466.53 $303.80 $356.96 $435.65 $511.88$404.07 $474.79 $399.65 $469.58 $305.78 $359.30 $438.50 $515.23$406.70 $477.87 $402.25 $472.64 $307.77 $361.63 $441.35 $518.59$409.33 $480.96 $404.84 $475.69 $309.76 $363.97 $444.20 $521.94$414.59 $487.14 $410.04 $481.80 $313.74 $368.64 $449.91 $528.64$419.84 $514.31 $415.24 $508.67 $317.72 $389.20 $455.61 $558.12$427.73 $523.96 $423.04 $518.22 $323.68 $396.51 $464.17 $568.60$435.28 $533.22 $430.51 $527.38 $329.40 $403.52 $472.37 $578.65$445.79 $546.10 $440.91 $540.11 $337.36 $413.26 $483.77 $592.62$458.93 $562.20 $453.91 $556.04 $347.30 $425.44 $498.03 $610.09$474.37 $581.11 $469.18 $574.74 $358.99 $439.76 $514.79 $630.62$492.77 $603.65 $487.37 $597.03 $372.91 $456.81 $534.75 $655.07$513.47 $629.00 $507.84 $622.11 $388.57 $476.00 $557.21 $682.59$537.12 $657.97 $531.24 $650.76 $406.47 $497.92 $582.88 $714.03$560.45 $686.55 $554.31 $679.02 $424.12 $519.55 $608.19 $745.04$586.73 $806.75 $580.30 $797.91 $444.01 $610.51 $636.71 $875.48$612.68 $842.43 $605.97 $833.20 $463.65 $637.52 $664.88 $914.21$641.26 $881.73 $634.23 $872.07 $485.28 $667.26 $695.89 $956.85$670.17 $921.48 $662.83 $911.39 $507.15 $697.34 $727.26 $999.99$701.38 $964.40 $693.69 $953.83 $530.77 $729.81 $761.13 $1,046.56$732.59 $1,007.31 $724.56 $996.27 $554.39 $762.29 $795.00 $1,093.12$766.42 $1,053.83 $758.03 $1,042.29 $580.00 $797.49 $831.72 $1,143.61$800.59 $1,100.81 $791.82 $1,088.75 $605.85 $833.04 $868.80 $1,194.59$837.05 $1,150.95 $827.88 $1,138.34 $633.45 $870.99 $908.37 $1,249.01$855.12 $1,175.79 $845.75 $1,162.91 $647.12 $889.79 $927.98 $1,275.97$891.59 $1,225.93 $881.82 $1,212.50 $674.71 $927.73 $967.55 $1,330.38$923.13 $1,269.30 $913.01 $1,255.39 $698.58 $960.55 $1,001.77 $1,377.44$943.82 $1,297.76 $933.48 $1,283.54 $714.24 $982.08 $1,024.23 $1,408.32$969.77 $1,333.44 $959.15 $1,318.83 $733.88 $1,009.09 $1,052.39 $1,447.04$985.53 $1,355.12 $974.75 $1,340.28 $745.82 $1,025.50 $1,069.50 $1,470.57

$4,25030%








$3,250 $6,850 $00%/20%/30%50% 50%


$7,900 $7,900Yes Yes



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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$207.36 $207.36 $306.90 $306.90 $246.52 $246.52 $235.14 $235.14$225.79 $225.79 $334.18 $334.18 $268.43 $268.43 $256.05 $256.05$232.84 $232.84 $344.62 $344.62 $276.81 $276.81 $264.04 $264.04$239.88 $239.88 $355.05 $355.05 $285.19 $285.19 $272.03 $272.03$247.47 $247.47 $366.28 $366.28 $294.21 $294.21 $280.64 $280.64$255.06 $255.06 $377.51 $377.51 $303.24 $303.24 $289.24 $289.24$262.92 $262.92 $389.15 $389.15 $312.58 $312.58 $298.16 $298.16$271.05 $304.94 $401.18 $451.33 $322.25 $362.53 $307.38 $345.80$271.05 $304.94 $401.18 $451.33 $322.25 $362.53 $307.38 $345.80$271.05 $304.94 $401.18 $451.33 $322.25 $362.53 $307.38 $345.80$271.05 $304.94 $401.18 $451.33 $322.25 $362.53 $307.38 $345.80$272.14 $306.16 $402.79 $453.14 $323.54 $363.98 $308.61 $347.18$277.56 $312.25 $410.81 $462.16 $329.98 $371.23 $314.76 $354.10$284.06 $319.57 $420.44 $472.99 $337.72 $379.93 $322.13 $362.40$294.64 $331.46 $436.08 $490.60 $350.29 $394.07 $334.12 $375.89$303.31 $341.22 $448.92 $505.04 $360.60 $405.67 $343.96 $386.95$307.65 $361.48 $455.34 $535.03 $365.75 $429.76 $348.87 $409.93$314.15 $369.13 $464.97 $546.34 $373.49 $438.85 $356.25 $418.60$320.66 $376.77 $474.60 $557.65 $381.22 $447.94 $363.63 $427.26$324.72 $381.55 $480.62 $564.72 $386.06 $453.61 $368.24 $432.68$329.06 $386.64 $487.03 $572.27 $391.21 $459.67 $373.16 $438.46$331.23 $389.19 $490.24 $576.04 $393.79 $462.70 $375.62 $441.35$333.40 $391.74 $493.45 $579.81 $396.37 $465.73 $378.08 $444.24$335.56 $394.29 $496.66 $583.58 $398.95 $468.76 $380.53 $447.13$337.73 $396.84 $499.87 $587.35 $401.52 $471.79 $382.99 $450.02$342.07 $401.93 $506.29 $594.89 $406.68 $477.85 $387.91 $455.80$346.41 $424.35 $512.71 $628.07 $411.84 $504.50 $392.83 $481.22$352.91 $432.32 $522.34 $639.87 $419.57 $513.97 $400.21 $490.25$359.15 $439.95 $531.57 $651.17 $426.98 $523.05 $407.28 $498.91$367.82 $450.58 $544.40 $666.89 $437.29 $535.68 $417.11 $510.96$378.66 $463.86 $560.45 $686.55 $450.18 $551.47 $429.41 $526.02$391.40 $479.47 $579.31 $709.65 $465.33 $570.03 $443.85 $543.72$406.58 $498.06 $601.77 $737.17 $483.37 $592.13 $461.07 $564.81$423.66 $518.98 $627.05 $768.13 $503.68 $617.00 $480.43 $588.53$443.17 $542.89 $655.93 $803.52 $526.88 $645.43 $502.56 $615.64$462.42 $566.46 $684.42 $838.41 $549.76 $673.45 $524.39 $642.37$484.10 $665.64 $716.51 $985.20 $575.54 $791.36 $548.98 $754.84$505.52 $695.08 $748.20 $1,028.78 $601.00 $826.37 $573.26 $788.23$529.10 $727.51 $783.11 $1,076.77 $629.03 $864.92 $600.00 $825.00$552.95 $760.31 $818.41 $1,125.32 $657.39 $903.91 $627.05 $862.20$578.70 $795.71 $856.52 $1,177.72 $688.00 $946.00 $656.25 $902.35$604.45 $831.12 $894.64 $1,230.12 $718.62 $988.10 $685.45 $942.50$632.37 $869.51 $935.96 $1,286.94 $751.81 $1,033.74 $717.11 $986.03$660.56 $908.27 $977.68 $1,344.31 $785.32 $1,079.82 $749.08 $1,029.99$690.65 $949.64 $1,022.21 $1,405.54 $821.09 $1,129.00 $783.20 $1,076.90$705.55 $970.14 $1,044.28 $1,435.88 $838.82 $1,153.37 $800.11 $1,100.15$735.64 $1,011.51 $1,088.81 $1,497.11 $874.59 $1,202.56 $834.22 $1,147.06$761.66 $1,047.28 $1,127.32 $1,550.07 $905.52 $1,245.09 $863.73 $1,187.63$778.74 $1,070.76 $1,152.60 $1,584.82 $925.82 $1,273.01 $883.10 $1,214.26$800.15 $1,100.21 $1,184.29 $1,628.40 $951.28 $1,308.01 $907.38 $1,247.65$813.15 $1,118.10 $1,203.54 $1,654.88 $966.75 $1,329.28 $922.13 $1,267.94







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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$345.83 $345.83 $400.73 $400.73 $383.10 $383.10 $313.25 $313.25$376.57 $376.57 $436.35 $436.35 $417.16 $417.16 $341.09 $341.09$388.32 $388.32 $449.97 $449.97 $430.18 $430.18 $351.74 $351.74$400.07 $400.07 $463.59 $463.59 $443.20 $443.20 $362.38 $362.38$412.73 $412.73 $478.25 $478.25 $457.22 $457.22 $373.85 $373.85$425.39 $425.39 $492.92 $492.92 $471.24 $471.24 $385.31 $385.31$438.50 $438.50 $508.11 $508.11 $485.76 $485.76 $397.19 $397.19$452.06 $508.57 $523.83 $589.31 $500.79 $563.39 $409.47 $460.66$452.06 $508.57 $523.83 $589.31 $500.79 $563.39 $409.47 $460.66$452.06 $508.57 $523.83 $589.31 $500.79 $563.39 $409.47 $460.66$452.06 $508.57 $523.83 $589.31 $500.79 $563.39 $409.47 $460.66$453.87 $510.60 $525.92 $591.66 $502.79 $565.64 $411.11 $462.50$462.91 $520.77 $536.40 $603.45 $512.81 $576.91 $419.30 $471.71$473.76 $532.98 $548.97 $617.59 $524.83 $590.43 $429.13 $482.77$491.39 $552.81 $569.40 $640.57 $544.36 $612.40 $445.10 $500.73$505.86 $569.09 $586.16 $659.43 $560.38 $630.43 $458.20 $515.47$513.09 $602.88 $594.54 $698.59 $568.39 $667.86 $464.75 $546.08$523.94 $615.63 $607.12 $713.36 $580.41 $681.99 $474.58 $557.63$534.79 $628.38 $619.69 $728.13 $592.43 $696.11 $484.41 $569.18$541.57 $636.34 $627.54 $737.36 $599.94 $704.93 $490.55 $576.39$548.80 $644.84 $635.93 $747.21 $607.96 $714.35 $497.10 $584.09$552.42 $649.09 $640.12 $752.14 $611.96 $719.06 $500.38 $587.94$556.03 $653.34 $644.31 $757.06 $615.97 $723.76 $503.65 $591.79$559.65 $657.59 $648.50 $761.98 $619.98 $728.47 $506.93 $595.64$563.27 $661.84 $652.69 $766.91 $623.98 $733.18 $510.20 $599.49$570.50 $670.34 $661.07 $776.76 $631.99 $742.59 $516.75 $607.19$577.73 $707.72 $669.45 $820.08 $640.01 $784.01 $523.31 $641.05$588.58 $721.01 $682.02 $835.48 $652.03 $798.73 $533.13 $653.09$598.98 $733.75 $694.07 $850.24 $663.54 $812.84 $542.55 $664.62$613.45 $751.47 $710.83 $870.77 $679.57 $832.47 $555.65 $680.68$631.53 $773.62 $731.79 $896.44 $699.60 $857.01 $572.03 $700.74$652.78 $799.65 $756.41 $926.60 $723.14 $885.84 $591.28 $724.32$678.09 $830.66 $785.74 $962.53 $751.18 $920.20 $614.21 $752.41$706.57 $865.55 $818.74 $1,002.96 $782.73 $958.85 $640.01 $784.01$739.12 $905.42 $856.46 $1,049.16 $818.79 $1,003.02 $669.49 $820.12$771.22 $944.74 $893.65 $1,094.72 $854.34 $1,046.57 $698.56 $855.74$807.38 $1,110.15 $935.55 $1,286.39 $894.41 $1,229.81 $731.32 $1,005.56$843.09 $1,159.25 $976.94 $1,343.29 $933.97 $1,284.21 $763.67 $1,050.04$882.42 $1,213.33 $1,022.51 $1,405.95 $977.54 $1,344.12 $799.29 $1,099.02$922.20 $1,268.03 $1,068.61 $1,469.33 $1,021.61 $1,404.71 $835.32 $1,148.57$965.15 $1,327.08 $1,118.37 $1,537.76 $1,069.18 $1,470.13 $874.22 $1,202.06

$1,008.10 $1,386.13 $1,168.13 $1,606.18 $1,116.76 $1,535.54 $913.12 $1,255.54$1,054.66 $1,450.15 $1,222.09 $1,680.37 $1,168.34 $1,606.47 $955.30 $1,313.54$1,101.67 $1,514.80 $1,276.57 $1,755.28 $1,220.42 $1,678.08 $997.88 $1,372.09$1,151.85 $1,583.79 $1,334.71 $1,835.23 $1,276.01 $1,754.51 $1,043.34 $1,434.59$1,176.71 $1,617.98 $1,363.52 $1,874.84 $1,303.55 $1,792.38 $1,065.86 $1,465.55$1,226.89 $1,686.98 $1,421.67 $1,954.79 $1,359.14 $1,868.82 $1,111.31 $1,528.05$1,270.29 $1,746.65 $1,471.95 $2,023.94 $1,407.21 $1,934.92 $1,150.62 $1,582.10$1,298.77 $1,785.81 $1,504.95 $2,069.31 $1,438.76 $1,978.30 $1,176.41 $1,617.57$1,334.48 $1,834.91 $1,546.34 $2,126.21 $1,478.33 $2,032.70 $1,208.76 $1,662.05$1,356.18 $1,864.75 $1,571.48 $2,160.79 $1,502.36 $2,065.75 $1,228.41 $1,689.07




$0 $0 $0$00% 0% 0% 0%

$10/$20 $20/$40 $35/$70$30/$60$5,000 $4,000 $4,500 $7,900

Yes Yes YesYes



Rate Pages









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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$313.17 $313.17 $262.84 $262.84 $259.55 $259.55 $198.12 $198.12$341.00 $341.00 $286.20 $286.20 $282.62 $282.62 $215.73 $215.73$351.65 $351.65 $295.14 $295.14 $291.45 $291.45 $222.47 $222.47$362.29 $362.29 $304.07 $304.07 $300.27 $300.27 $229.20 $229.20$373.75 $373.75 $313.69 $313.69 $309.77 $309.77 $236.45 $236.45$385.22 $385.22 $323.31 $323.31 $319.27 $319.27 $243.70 $243.70$397.09 $397.09 $333.27 $333.27 $329.11 $329.11 $251.21 $251.21$409.37 $460.54 $343.58 $386.53 $339.28 $381.70 $258.98 $291.36$409.37 $460.54 $343.58 $386.53 $339.28 $381.70 $258.98 $291.36$409.37 $460.54 $343.58 $386.53 $339.28 $381.70 $258.98 $291.36$409.37 $460.54 $343.58 $386.53 $339.28 $381.70 $258.98 $291.36$411.01 $462.38 $344.95 $388.07 $340.64 $383.22 $260.02 $292.52$419.19 $471.59 $351.83 $395.80 $347.43 $390.86 $265.20 $298.35$429.02 $482.65 $360.07 $405.08 $355.57 $400.02 $271.41 $305.34$444.98 $500.61 $373.47 $420.16 $368.80 $414.90 $281.52 $316.70$458.08 $515.35 $384.47 $432.52 $379.66 $427.12 $289.80 $326.03$464.63 $545.95 $389.96 $458.21 $385.09 $452.48 $293.95 $345.39$474.46 $557.49 $398.21 $467.90 $393.23 $462.05 $300.16 $352.69$484.28 $569.03 $406.46 $477.58 $401.37 $471.61 $306.38 $359.99$490.42 $576.25 $411.61 $483.64 $406.46 $477.59 $310.26 $364.56$496.97 $583.95 $417.11 $490.10 $411.89 $483.97 $314.41 $369.43$500.25 $587.79 $419.85 $493.33 $414.61 $487.16 $316.48 $371.86$503.52 $591.64 $422.60 $496.56 $417.32 $490.35 $318.55 $374.30$506.80 $595.49 $425.35 $499.79 $420.03 $493.54 $320.62 $376.73$510.07 $599.34 $428.10 $503.02 $422.75 $496.73 $322.69 $379.17$516.62 $607.03 $433.60 $509.48 $428.18 $503.11 $326.84 $384.03$523.17 $640.89 $439.10 $537.89 $433.61 $531.17 $330.98 $405.45$533.00 $652.92 $447.34 $547.99 $441.75 $541.14 $337.20 $413.07$542.41 $664.46 $455.24 $557.67 $449.55 $550.70 $343.15 $420.36$555.51 $680.51 $466.24 $571.14 $460.41 $564.00 $351.44 $430.52$571.89 $700.56 $479.98 $587.98 $473.98 $580.63 $361.80 $443.21$591.13 $724.13 $496.13 $607.76 $489.93 $600.16 $373.97 $458.12$614.05 $752.22 $515.37 $631.33 $508.93 $623.44 $388.48 $475.88$639.84 $783.81 $537.02 $657.84 $530.30 $649.62 $404.79 $495.87$669.32 $819.92 $561.75 $688.15 $554.73 $679.55 $423.44 $518.71$698.38 $855.52 $586.15 $718.03 $578.82 $709.05 $441.83 $541.24$731.13 $1,005.31 $613.63 $843.75 $605.96 $833.20 $462.54 $636.00$763.47 $1,049.78 $640.78 $881.07 $632.77 $870.05 $483.00 $664.13$799.09 $1,098.75 $670.67 $922.17 $662.28 $910.64 $505.54 $695.11$835.11 $1,148.28 $700.90 $963.74 $692.14 $951.69 $528.33 $726.45$874.00 $1,201.76 $733.54 $1,008.62 $724.37 $996.01 $552.93 $760.28$912.89 $1,255.23 $766.18 $1,053.50 $756.61 $1,040.33 $577.53 $794.11$955.06 $1,313.21 $801.57 $1,102.16 $791.55 $1,088.38 $604.21 $830.79$997.63 $1,371.75 $837.30 $1,151.29 $826.84 $1,136.90 $631.14 $867.82

$1,043.07 $1,434.23 $875.44 $1,203.73 $864.50 $1,188.68 $659.89 $907.35$1,065.59 $1,465.18 $894.34 $1,229.72 $883.16 $1,214.34 $674.13 $926.94$1,111.03 $1,527.66 $932.48 $1,282.15 $920.82 $1,266.13 $702.88 $966.46$1,150.33 $1,581.70 $965.46 $1,327.51 $953.39 $1,310.91 $727.74 $1,000.65$1,176.12 $1,617.16 $987.11 $1,357.27 $974.77 $1,340.30 $744.06 $1,023.08$1,208.46 $1,661.63 $1,014.25 $1,394.59 $1,001.57 $1,377.16 $764.52 $1,051.21$1,228.11 $1,688.65 $1,030.74 $1,417.27 $1,017.84 $1,399.55 $776.94 $1,068.31







Plan Design Summary























Plan Design Summary



Rates by County


RATING AREA 827,377 16,768 16,060 31,650 22,510






Rate Pages









0‐14 $392.99 $392.99 $375.71 $375.71 $307.74 $307.74 $308.29 $308.2915 $427.92 $427.92 $409.10 $409.10 $335.09 $335.09 $335.70 $335.7016 $441.28 $441.28 $421.87 $421.87 $345.55 $345.55 $346.17 $346.1717 $454.64 $454.64 $434.64 $434.64 $356.01 $356.01 $356.65 $356.6518 $469.02 $469.02 $448.39 $448.39 $367.27 $367.27 $367.94 $367.9419 $483.40 $483.40 $462.14 $462.14 $378.53 $378.53 $379.22 $379.2220 $498.30 $498.30 $476.39 $476.39 $390.20 $390.20 $390.91 $390.9121 $513.71 $577.93 $491.12 $552.51 $402.27 $452.55 $403.00 $453.3722 $513.71 $577.93 $491.12 $552.51 $402.27 $452.55 $403.00 $453.3723 $513.71 $577.93 $491.12 $552.51 $402.27 $452.55 $403.00 $453.3724 $513.71 $577.93 $491.12 $552.51 $402.27 $452.55 $403.00 $453.3725 $515.77 $580.24 $493.09 $554.72 $403.88 $454.36 $404.61 $455.1826 $526.04 $591.80 $502.91 $565.77 $411.92 $463.41 $412.67 $464.2527 $538.37 $605.67 $514.69 $579.03 $421.58 $474.27 $422.34 $475.1328 $558.41 $628.21 $533.85 $600.58 $437.27 $491.92 $438.06 $492.8129 $574.84 $646.70 $549.56 $618.26 $450.14 $506.41 $450.95 $507.3230 $583.06 $685.10 $557.42 $654.97 $456.57 $536.48 $457.40 $537.4531 $595.39 $699.59 $569.21 $668.82 $466.23 $547.82 $467.07 $548.8132 $607.72 $714.07 $581.00 $682.67 $475.88 $559.16 $476.74 $560.1833 $615.43 $723.13 $588.36 $691.33 $481.92 $566.25 $482.79 $567.2834 $623.65 $732.79 $596.22 $700.56 $488.35 $573.82 $489.24 $574.8535 $627.76 $737.61 $600.15 $705.18 $491.57 $577.60 $492.46 $578.6436 $631.87 $742.44 $604.08 $709.79 $494.79 $581.38 $495.69 $582.4337 $635.98 $747.27 $608.01 $714.41 $498.01 $585.16 $498.91 $586.2238 $640.09 $752.10 $611.94 $719.03 $501.23 $588.94 $502.13 $590.0139 $648.31 $761.76 $619.79 $728.26 $507.66 $596.50 $508.58 $597.5840 $656.52 $804.24 $627.65 $768.87 $514.10 $629.77 $515.03 $630.9141 $668.85 $819.35 $639.44 $783.31 $523.75 $641.60 $524.70 $642.7642 $680.67 $833.82 $650.74 $797.15 $533.01 $652.93 $533.97 $654.1143 $697.11 $853.96 $666.45 $816.40 $545.88 $668.70 $546.87 $669.9144 $717.66 $879.13 $686.10 $840.47 $561.97 $688.41 $562.99 $689.6645 $741.80 $908.71 $709.18 $868.74 $580.88 $711.57 $581.93 $712.8646 $770.57 $943.95 $736.68 $902.43 $603.40 $739.17 $604.49 $740.5147 $802.93 $983.59 $767.62 $940.34 $628.75 $770.21 $629.88 $771.6148 $839.92 $1,028.90 $802.98 $983.65 $657.71 $805.69 $658.90 $807.1549 $876.39 $1,073.58 $837.85 $1,026.37 $686.27 $840.68 $687.51 $842.2050 $917.49 $1,261.55 $877.14 $1,206.07 $718.45 $987.87 $719.75 $989.6651 $958.07 $1,317.35 $915.94 $1,259.42 $750.23 $1,031.57 $751.59 $1,033.4352 $1,002.77 $1,378.80 $958.67 $1,318.17 $785.23 $1,079.69 $786.65 $1,081.6453 $1,047.97 $1,440.96 $1,001.89 $1,377.59 $820.63 $1,128.36 $822.11 $1,130.4154 $1,096.78 $1,508.07 $1,048.54 $1,441.75 $858.84 $1,180.91 $860.40 $1,183.0555 $1,145.58 $1,575.17 $1,095.20 $1,505.90 $897.06 $1,233.46 $898.68 $1,235.6956 $1,198.49 $1,647.93 $1,145.78 $1,575.45 $938.49 $1,290.43 $940.19 $1,292.7657 $1,251.92 $1,721.39 $1,196.86 $1,645.68 $980.33 $1,347.95 $982.10 $1,350.3958 $1,308.94 $1,799.79 $1,251.38 $1,720.64 $1,024.98 $1,409.35 $1,026.84 $1,411.9059 $1,337.19 $1,838.64 $1,278.39 $1,757.78 $1,047.10 $1,439.77 $1,049.00 $1,442.3860 $1,394.22 $1,917.05 $1,332.90 $1,832.74 $1,091.76 $1,501.17 $1,093.73 $1,503.8861 $1,443.53 $1,984.86 $1,380.05 $1,897.57 $1,130.37 $1,554.26 $1,132.42 $1,557.0862 $1,475.90 $2,029.36 $1,410.99 $1,940.11 $1,155.72 $1,589.11 $1,157.81 $1,591.9963 $1,516.48 $2,085.16 $1,449.79 $1,993.46 $1,187.50 $1,632.81 $1,189.65 $1,635.7664+ $1,541.13 $2,119.06 $1,473.36 $2,025.87 $1,206.81 $1,659.36 $1,208.99 $1,662.36


HMOJuly 1, 2019

33871PA0100021

September 30, 2019




Yes


$00%

$35/$70$7,900

88

YesYes

$20/$400%$0

$6,000


$1,50010%

Yes



8

$10/$20

00%

$4,000


$4,500




Rate Pages









0‐141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364+

Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$257.60 $257.60 $254.77 $254.77 $194.94 $194.94 $279.54 $279.54$280.49 $280.49 $277.42 $277.42 $212.27 $212.27 $304.39 $304.39$289.25 $289.25 $286.08 $286.08 $218.89 $218.89 $313.89 $313.89$298.00 $298.00 $294.74 $294.74 $225.52 $225.52 $323.39 $323.39$307.43 $307.43 $304.06 $304.06 $232.65 $232.65 $333.62 $333.62$316.86 $316.86 $313.39 $313.39 $239.79 $239.79 $343.85 $343.85$326.63 $326.63 $323.05 $323.05 $247.18 $247.18 $354.45 $354.45$336.73 $378.82 $333.04 $374.67 $254.82 $286.67 $365.41 $411.09$336.73 $378.82 $333.04 $374.67 $254.82 $286.67 $365.41 $411.09$336.73 $378.82 $333.04 $374.67 $254.82 $286.67 $365.41 $411.09$336.73 $378.82 $333.04 $374.67 $254.82 $286.67 $365.41 $411.09$338.07 $380.33 $334.37 $376.17 $255.84 $287.82 $366.88 $412.74$344.81 $387.91 $341.03 $383.66 $260.94 $293.55 $374.18 $420.96$352.89 $397.00 $349.02 $392.65 $267.05 $300.43 $382.95 $430.82$366.02 $411.78 $362.01 $407.26 $276.99 $311.61 $397.21 $446.86$376.80 $423.90 $372.67 $419.25 $285.14 $320.79 $408.90 $460.01$382.19 $449.07 $378.00 $444.15 $289.22 $339.83 $414.75 $487.33$390.27 $458.56 $385.99 $453.54 $295.34 $347.02 $423.52 $497.63$398.35 $468.06 $393.98 $462.93 $301.45 $354.21 $432.29 $507.94$403.40 $473.99 $398.98 $468.80 $305.27 $358.70 $437.77 $514.38$408.79 $480.32 $404.31 $475.06 $309.35 $363.49 $443.61 $521.25$411.48 $483.49 $406.97 $478.19 $311.39 $365.88 $446.54 $524.68$414.17 $486.65 $409.64 $481.32 $313.43 $368.28 $449.46 $528.12$416.87 $489.82 $412.30 $484.45 $315.47 $370.67 $452.38 $531.55$419.56 $492.99 $414.97 $487.58 $317.51 $373.07 $455.31 $534.98$424.95 $499.32 $420.29 $493.85 $321.58 $377.86 $461.15 $541.85$430.34 $527.16 $425.62 $521.39 $325.66 $398.93 $467.00 $572.07$438.42 $537.06 $433.62 $531.18 $331.78 $406.43 $475.77 $582.82$446.16 $546.55 $441.28 $540.56 $337.64 $413.60 $484.17 $593.11$456.94 $559.75 $451.93 $553.62 $345.79 $423.59 $495.87 $607.44$470.41 $576.25 $465.25 $569.94 $355.98 $436.08 $510.48 $625.34$486.23 $595.64 $480.91 $589.11 $367.96 $450.75 $527.66 $646.38$505.09 $618.74 $499.56 $611.96 $382.23 $468.23 $548.12 $671.45$526.30 $644.72 $520.54 $637.66 $398.28 $487.90 $571.14 $699.65$550.55 $674.42 $544.52 $667.03 $416.63 $510.37 $597.45 $731.88$574.46 $703.71 $568.16 $696.00 $434.72 $532.54 $623.40 $763.66$601.39 $826.92 $594.81 $817.86 $455.11 $625.77 $652.63 $897.37$628.00 $863.49 $621.12 $854.03 $475.24 $653.45 $681.50 $937.06$657.29 $903.78 $650.09 $893.87 $497.41 $683.94 $713.29 $980.77$686.92 $944.52 $679.40 $934.17 $519.83 $714.77 $745.45 $1,024.99$718.91 $988.50 $711.04 $977.67 $544.04 $748.06 $780.16 $1,072.72$750.90 $1,032.49 $742.67 $1,021.18 $568.25 $781.34 $814.87 $1,120.45$785.58 $1,080.18 $776.98 $1,068.34 $594.49 $817.43 $852.51 $1,172.20$820.60 $1,128.33 $811.61 $1,115.97 $621.00 $853.87 $890.51 $1,224.46$857.98 $1,179.72 $848.58 $1,166.80 $649.28 $892.76 $931.08 $1,280.23$876.50 $1,205.19 $866.90 $1,191.98 $663.30 $912.03 $951.17 $1,307.86$913.88 $1,256.58 $903.86 $1,242.81 $691.58 $950.92 $991.73 $1,363.63$946.20 $1,301.03 $935.84 $1,286.77 $716.04 $984.56 $1,026.81 $1,411.87$967.42 $1,330.20 $956.82 $1,315.62 $732.10 $1,006.63 $1,049.84 $1,443.52$994.02 $1,366.77 $983.13 $1,351.80 $752.23 $1,034.31 $1,078.70 $1,483.22

$1,010.18 $1,389.00 $999.11 $1,373.78 $764.46 $1,051.13 $1,096.23 $1,507.33

Yes$7,900 $7,900Yes Yes

$15/$40, $30/$60, $45/$80$7,900

50% 50%$30 no ded/$60 no ded $50 no ded/$100 no ded

$00%/20%/30%

Silver Bronze$3,250 $6,850


8 8Keystone Health Plan East Network Keystone Health Plan East Network


Keystone HMO Silver Classic $3,250/$30/$60/50% Keystone HMO Bronze Essential $6,850/$50/$100/$700KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19

33871PA0100044Keystone HMO Gold Proactive

33871PA0100025 33871PA0100026




$4,25030%




Rate Pages









0‐141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364+

Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$212.54 $212.54 $314.58 $314.58 $252.68 $252.68 $241.02 $241.02$231.43 $231.43 $342.54 $342.54 $275.14 $275.14 $262.45 $262.45$238.66 $238.66 $353.23 $353.23 $283.73 $283.73 $270.64 $270.64$245.88 $245.88 $363.92 $363.92 $292.32 $292.32 $278.83 $278.83$253.66 $253.66 $375.44 $375.44 $301.57 $301.57 $287.65 $287.65$261.44 $261.44 $386.95 $386.95 $310.82 $310.82 $296.47 $296.47$269.49 $269.49 $398.87 $398.87 $320.40 $320.40 $305.61 $305.61$277.83 $312.56 $411.21 $462.61 $330.31 $371.59 $315.06 $354.45$277.83 $312.56 $411.21 $462.61 $330.31 $371.59 $315.06 $354.45$277.83 $312.56 $411.21 $462.61 $330.31 $371.59 $315.06 $354.45$277.83 $312.56 $411.21 $462.61 $330.31 $371.59 $315.06 $354.45$278.94 $313.81 $412.86 $464.46 $331.63 $373.08 $316.32 $355.86$284.50 $320.06 $421.08 $473.72 $338.23 $380.51 $322.62 $362.95$291.17 $327.56 $430.95 $484.82 $346.16 $389.43 $330.19 $371.46$302.00 $339.75 $446.99 $502.86 $359.04 $403.92 $342.47 $385.28$310.89 $349.75 $460.15 $517.66 $369.61 $415.81 $352.55 $396.62$315.34 $370.52 $466.72 $548.40 $374.90 $440.50 $357.60 $420.18$322.00 $378.36 $476.59 $560.00 $382.82 $449.82 $365.16 $429.06$328.67 $386.19 $486.46 $571.59 $390.75 $459.13 $372.72 $437.94$332.84 $391.09 $492.63 $578.84 $395.71 $464.95 $377.44 $443.50$337.29 $396.31 $499.21 $586.57 $400.99 $471.16 $382.49 $449.42$339.51 $398.92 $502.50 $590.44 $403.63 $474.27 $385.01 $452.38$341.73 $401.53 $505.79 $594.30 $406.28 $477.37 $387.53 $455.34$343.95 $404.15 $509.08 $598.17 $408.92 $480.48 $390.05 $458.31$346.18 $406.76 $512.37 $602.03 $411.56 $483.58 $392.57 $461.27$350.62 $411.98 $518.95 $609.76 $416.85 $489.79 $397.61 $467.19$355.07 $434.96 $525.53 $643.77 $422.13 $517.11 $402.65 $493.25$361.73 $443.12 $535.40 $655.86 $430.06 $526.82 $410.21 $502.51$368.12 $450.95 $544.85 $667.45 $437.66 $536.13 $417.46 $511.39$377.02 $461.84 $558.01 $683.57 $448.22 $549.08 $427.54 $523.74$388.13 $475.46 $574.46 $703.72 $461.44 $565.26 $440.14 $539.17$401.19 $491.45 $593.79 $727.39 $476.96 $584.28 $454.95 $557.31$416.74 $510.51 $616.82 $755.60 $495.46 $606.94 $472.59 $578.93$434.25 $531.95 $642.72 $787.34 $516.27 $632.43 $492.44 $603.24$454.25 $556.46 $672.33 $823.60 $540.05 $661.56 $515.13 $631.03$473.98 $580.62 $701.53 $859.37 $563.50 $690.29 $537.50 $658.43$496.20 $682.28 $734.42 $1,009.83 $589.93 $811.15 $562.70 $773.71$518.15 $712.46 $766.91 $1,054.50 $616.02 $847.03 $587.59 $807.94$542.32 $745.70 $802.68 $1,103.69 $644.76 $886.54 $615.00 $845.63$566.77 $779.31 $838.87 $1,153.45 $673.82 $926.51 $642.73 $883.75$593.17 $815.60 $877.94 $1,207.16 $705.20 $969.65 $672.66 $924.90$619.56 $851.90 $917.00 $1,260.88 $736.58 $1,012.80 $702.59 $966.06$648.18 $891.24 $959.36 $1,319.11 $770.60 $1,059.58 $735.04 $1,010.68$677.07 $930.97 $1,002.12 $1,377.92 $804.95 $1,106.81 $767.81 $1,055.73$707.91 $973.38 $1,047.77 $1,440.68 $841.62 $1,157.23 $802.78 $1,103.82$723.19 $994.39 $1,070.38 $1,471.78 $859.79 $1,182.21 $820.11 $1,127.65$754.03 $1,036.79 $1,116.03 $1,534.54 $896.45 $1,232.62 $855.08 $1,175.73$780.70 $1,073.47 $1,155.50 $1,588.82 $928.16 $1,276.22 $885.33 $1,217.32$798.21 $1,097.53 $1,181.41 $1,624.44 $948.97 $1,304.83 $905.17 $1,244.61$820.15 $1,127.71 $1,213.90 $1,669.11 $975.06 $1,340.71 $930.06 $1,278.84$833.49 $1,146.05 $1,233.63 $1,696.25 $990.92 $1,362.51 $945.18 $1,299.63

Yes Yes YesYes$7,900 $4,000 $7,900$7,900

0%/5%/10% 0% 0%0%$40/$80, $60 no ded/$120 no ded, $70 no ded/$140 no ded $40 no ded/$80 no ded $40 no ded/$80 no ded$40 no ded/$80 no ded

$0/$6000/$6000 $2,500 $5,000$4,500Silver Gold SilverSilver


KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19KE 670 WPR GMC Rev. 1.19Keystone HMO Silver Proactive Keystone HMO Gold Classic $2,500/$40/$80/100% Keystone HMO Silver Secure $5,000/$40/$80/$600Keystone HMO Silver Classic $4,500/$40/$80/100%

33871PA0100045 33871PA0100047 33871PA010004933871PA0100048



Rate Pages









0‐141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364+

Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$354.47 $354.47 $410.75 $410.75 $392.68 $392.68 $321.08 $321.08$385.98 $385.98 $447.26 $447.26 $427.59 $427.59 $349.62 $349.62$398.03 $398.03 $461.22 $461.22 $440.93 $440.93 $360.53 $360.53$410.08 $410.08 $475.18 $475.18 $454.28 $454.28 $371.44 $371.44$423.05 $423.05 $490.21 $490.21 $468.65 $468.65 $383.19 $383.19$436.02 $436.02 $505.24 $505.24 $483.02 $483.02 $394.95 $394.95$449.46 $449.46 $520.81 $520.81 $497.91 $497.91 $407.12 $407.12$463.36 $521.28 $536.92 $604.04 $513.31 $577.47 $419.71 $472.17$463.36 $521.28 $536.92 $604.04 $513.31 $577.47 $419.71 $472.17$463.36 $521.28 $536.92 $604.04 $513.31 $577.47 $419.71 $472.17$463.36 $521.28 $536.92 $604.04 $513.31 $577.47 $419.71 $472.17$465.22 $523.37 $539.07 $606.45 $515.36 $579.78 $421.39 $474.06$474.48 $533.79 $549.81 $618.53 $525.63 $591.33 $429.78 $483.50$485.60 $546.30 $562.69 $633.03 $537.95 $605.19 $439.85 $494.84$503.67 $566.63 $583.63 $656.59 $557.97 $627.71 $456.22 $513.25$518.50 $583.31 $600.82 $675.92 $574.39 $646.19 $469.65 $528.36$525.92 $617.95 $609.41 $716.05 $582.60 $684.56 $476.37 $559.73$537.04 $631.02 $622.29 $731.19 $594.92 $699.03 $486.44 $571.57$548.16 $644.08 $635.18 $746.33 $607.24 $713.51 $496.52 $583.41$555.11 $652.25 $643.23 $755.80 $614.94 $722.56 $502.81 $590.80$562.52 $660.96 $651.82 $765.89 $623.16 $732.21 $509.53 $598.69$566.23 $665.32 $656.12 $770.94 $627.26 $737.03 $512.88 $602.64$569.93 $669.67 $660.41 $775.99 $631.37 $741.86 $516.24 $606.58$573.64 $674.03 $664.71 $781.03 $635.47 $746.68 $519.60 $610.53$577.35 $678.38 $669.00 $786.08 $639.58 $751.51 $522.96 $614.47$584.76 $687.10 $677.60 $796.17 $647.79 $761.16 $529.67 $622.37$592.18 $725.42 $686.19 $840.58 $656.01 $803.61 $536.39 $657.08$603.30 $739.04 $699.07 $856.36 $668.33 $818.70 $546.46 $669.41$613.95 $752.09 $711.42 $871.49 $680.13 $833.16 $556.11 $681.24$628.78 $770.26 $728.60 $892.54 $696.56 $853.28 $569.54 $697.69$647.32 $792.96 $750.08 $918.85 $717.09 $878.44 $586.33 $718.26$669.09 $819.64 $775.32 $949.76 $741.22 $907.99 $606.06 $742.42$695.04 $851.43 $805.38 $986.59 $769.96 $943.20 $629.56 $771.21$724.23 $887.19 $839.21 $1,028.03 $802.30 $982.82 $656.00 $803.61$757.60 $928.06 $877.87 $1,075.39 $839.26 $1,028.09 $686.22 $840.62$790.49 $968.36 $915.99 $1,122.09 $875.70 $1,072.74 $716.02 $877.13$827.56 $1,137.90 $958.94 $1,318.55 $916.77 $1,260.55 $749.60 $1,030.70$864.17 $1,188.23 $1,001.36 $1,376.87 $957.32 $1,316.31 $782.76 $1,076.29$904.48 $1,243.66 $1,048.07 $1,441.10 $1,001.98 $1,377.72 $819.27 $1,126.50$945.26 $1,299.73 $1,095.32 $1,506.07 $1,047.15 $1,439.83 $856.21 $1,177.28$989.28 $1,360.26 $1,146.33 $1,576.20 $1,095.91 $1,506.88 $896.08 $1,232.11

$1,033.30 $1,420.78 $1,197.34 $1,646.34 $1,144.68 $1,573.93 $935.95 $1,286.93$1,081.02 $1,486.41 $1,252.64 $1,722.38 $1,197.55 $1,646.63 $979.18 $1,346.37$1,129.21 $1,552.67 $1,308.48 $1,799.16 $1,250.93 $1,720.03 $1,022.83 $1,406.39$1,180.65 $1,623.39 $1,368.08 $1,881.11 $1,307.91 $1,798.37 $1,069.42 $1,470.45$1,206.13 $1,658.43 $1,397.61 $1,921.71 $1,336.14 $1,837.19 $1,092.50 $1,502.19$1,257.56 $1,729.15 $1,457.21 $2,003.66 $1,393.12 $1,915.53 $1,139.09 $1,566.25$1,302.05 $1,790.31 $1,508.75 $2,074.53 $1,442.39 $1,983.29 $1,179.38 $1,621.65$1,331.24 $1,830.45 $1,542.58 $2,121.04 $1,474.73 $2,027.76 $1,205.82 $1,658.01$1,367.84 $1,880.78 $1,584.99 $2,179.37 $1,515.28 $2,083.51 $1,238.98 $1,703.60$1,390.08 $1,911.37 $1,610.76 $2,214.80 $1,539.92 $2,117.39 $1,259.13 $1,731.30

$4,000 $4,500 $7,900Yes Yes YesYes

$5,000

0% 0% 0%$10/$20 $20/$40 $35/$70$30/$60

0%

Platinum Platinum Gold$0 $0 $0$0

Platinum


8

Keystone DPOS Platinum Preferred $10/$20/$150 Keystone DPOS Platinum Preferred $20/$40/$200 Keystone DPOS Gold Preferred $35/$70/$650KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19 KE 670 WPR GMC Rev. 1.19KE 670 WPR GMC Rev. 1.19

Keystone HMO Platinum Preferred $30/$60/$40033871PA0110011 33871PA0110012 33871PA011001333871PA0100050



Rate Pages









0‐141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364+

Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$321.00 $321.00 $269.41 $269.41 $266.04 $266.04 $203.08 $203.08$349.53 $349.53 $293.36 $293.36 $289.69 $289.69 $221.13 $221.13$360.44 $360.44 $302.51 $302.51 $298.73 $298.73 $228.03 $228.03$371.35 $371.35 $311.67 $311.67 $307.77 $307.77 $234.93 $234.93$383.10 $383.10 $321.53 $321.53 $317.51 $317.51 $242.36 $242.36$394.85 $394.85 $331.39 $331.39 $327.25 $327.25 $249.80 $249.80$407.02 $407.02 $341.60 $341.60 $337.33 $337.33 $257.49 $257.49$419.60 $472.05 $352.17 $396.19 $347.77 $391.24 $265.46 $298.64$419.60 $472.05 $352.17 $396.19 $347.77 $391.24 $265.46 $298.64$419.60 $472.05 $352.17 $396.19 $347.77 $391.24 $265.46 $298.64$419.60 $472.05 $352.17 $396.19 $347.77 $391.24 $265.46 $298.64$421.28 $473.94 $353.58 $397.78 $349.16 $392.80 $266.52 $299.83$429.67 $483.38 $360.62 $405.70 $356.11 $400.63 $271.83 $305.81$439.74 $494.71 $369.07 $415.21 $364.46 $410.02 $278.20 $312.98$456.11 $513.12 $382.81 $430.66 $378.02 $425.28 $288.55 $324.62$469.54 $528.23 $394.08 $443.34 $389.15 $437.79 $297.05 $334.18$476.25 $559.59 $399.71 $469.66 $394.72 $463.79 $301.29 $354.02$486.32 $571.43 $408.16 $479.59 $403.06 $473.60 $307.67 $361.51$496.39 $583.26 $416.62 $489.52 $411.41 $483.40 $314.04 $368.99$502.68 $590.65 $421.90 $495.73 $416.62 $489.53 $318.02 $373.67$509.40 $598.54 $427.53 $502.35 $422.19 $496.07 $322.27 $378.66$512.76 $602.49 $430.35 $505.66 $424.97 $499.34 $324.39 $381.16$516.11 $606.43 $433.17 $508.97 $427.75 $502.61 $326.51 $383.65$519.47 $610.38 $435.99 $512.28 $430.54 $505.88 $328.64 $386.15$522.83 $614.32 $438.80 $515.59 $433.32 $509.15 $330.76 $388.64$529.54 $622.21 $444.44 $522.21 $438.88 $515.69 $335.01 $393.63$536.25 $656.91 $450.07 $551.34 $444.45 $544.45 $339.26 $415.59$546.32 $669.25 $458.52 $561.69 $452.79 $554.67 $345.63 $423.39$555.97 $681.07 $466.62 $571.61 $460.79 $564.47 $351.73 $430.87$569.40 $697.52 $477.89 $585.42 $471.92 $578.10 $360.23 $441.28$586.19 $718.08 $491.98 $602.68 $485.83 $595.14 $370.84 $454.28$605.91 $742.24 $508.53 $622.95 $502.17 $615.16 $383.32 $469.57$629.41 $771.02 $528.25 $647.11 $521.65 $639.02 $398.19 $487.78$655.84 $803.40 $550.44 $674.29 $543.56 $665.86 $414.91 $508.27$686.05 $840.41 $575.80 $705.35 $568.60 $696.53 $434.02 $531.68$715.84 $876.91 $600.80 $735.98 $593.29 $726.78 $452.87 $554.77$749.41 $1,030.44 $628.97 $864.84 $621.11 $854.03 $474.11 $651.90$782.56 $1,076.02 $656.80 $903.09 $648.58 $891.80 $495.08 $680.73$819.07 $1,126.22 $687.43 $945.22 $678.84 $933.41 $518.17 $712.49$855.99 $1,176.99 $718.43 $987.83 $709.44 $975.49 $541.53 $744.61$895.85 $1,231.80 $751.88 $1,033.84 $742.48 $1,020.91 $566.75 $779.29$935.72 $1,286.61 $785.34 $1,079.84 $775.52 $1,066.34 $591.97 $813.96$978.93 $1,346.04 $821.61 $1,129.71 $811.34 $1,115.59 $619.31 $851.56

$1,022.57 $1,406.04 $858.24 $1,180.07 $847.51 $1,165.32 $646.92 $889.52$1,069.15 $1,470.08 $897.33 $1,233.82 $886.11 $1,218.40 $676.39 $930.03$1,092.23 $1,501.81 $916.70 $1,260.46 $905.24 $1,244.70 $690.99 $950.11$1,138.80 $1,565.85 $955.79 $1,314.21 $943.84 $1,297.78 $720.45 $990.62$1,179.09 $1,621.24 $989.60 $1,360.69 $977.22 $1,343.68 $745.94 $1,025.66$1,205.52 $1,657.59 $1,011.78 $1,391.20 $999.13 $1,373.81 $762.66 $1,048.66$1,238.67 $1,703.17 $1,039.60 $1,429.45 $1,026.61 $1,411.58 $783.63 $1,077.49$1,258.80 $1,730.86 $1,056.51 $1,452.70 $1,043.30 $1,434.54 $796.37 $1,095.01

Yes Yes Yes Yes

$25 no ded/$50 no ded $25 no ded/$50 no ded $30 no ded/$60 no ded $50 no ded/$100 no ded$6,000 $7,900 $7,900 $7,900

$1,500 $4,250 $3,250 $6,85010% 30% 50% 50%

Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network Keystone Health Plan East Network Gold Silver Silver Bronze





Plan Design Summary























Plan Design Summary



Rates by County


RATING AREA 827,377 16,768 16,060 31,650 22,510






Rate Pages









0‐14 $402.81 $402.81 $385.10 $385.10 $315.43 $315.43 $316.00 $316.0015 $438.62 $438.62 $419.33 $419.33 $343.47 $343.47 $344.09 $344.0916 $452.31 $452.31 $432.42 $432.42 $354.19 $354.19 $354.83 $354.8317 $466.00 $466.00 $445.51 $445.51 $364.91 $364.91 $365.57 $365.5718 $480.74 $480.74 $459.60 $459.60 $376.45 $376.45 $377.13 $377.1319 $495.49 $495.49 $473.70 $473.70 $388.00 $388.00 $388.70 $388.7020 $510.76 $510.76 $488.30 $488.30 $399.96 $399.96 $400.68 $400.6821 $526.55 $592.37 $503.40 $566.32 $412.32 $463.87 $413.07 $464.7022 $526.55 $592.37 $503.40 $566.32 $412.32 $463.87 $413.07 $464.7023 $526.55 $592.37 $503.40 $566.32 $412.32 $463.87 $413.07 $464.7024 $526.55 $592.37 $503.40 $566.32 $412.32 $463.87 $413.07 $464.7025 $528.66 $594.74 $505.41 $568.59 $413.97 $465.72 $414.72 $466.5626 $539.19 $606.59 $515.48 $579.91 $422.22 $475.00 $422.98 $475.8627 $551.83 $620.81 $527.56 $593.51 $432.12 $486.13 $432.90 $487.0128 $572.37 $643.91 $547.19 $615.59 $448.20 $504.22 $449.01 $505.1329 $589.21 $662.87 $563.30 $633.72 $461.39 $519.07 $462.23 $520.0030 $597.64 $702.23 $571.36 $671.34 $467.99 $549.89 $468.84 $550.8831 $610.28 $717.08 $583.44 $685.54 $477.88 $561.51 $478.75 $562.5332 $622.91 $731.92 $595.52 $699.74 $487.78 $573.14 $488.66 $574.1833 $630.81 $741.20 $603.07 $708.61 $493.97 $580.41 $494.86 $581.4634 $639.24 $751.10 $611.13 $718.07 $500.56 $588.16 $501.47 $589.2335 $643.45 $756.05 $615.15 $722.80 $503.86 $592.04 $504.77 $593.1136 $647.66 $761.00 $619.18 $727.54 $507.16 $595.91 $508.08 $596.9937 $651.87 $765.95 $623.21 $732.27 $510.46 $599.79 $511.38 $600.8738 $656.09 $770.90 $627.23 $737.00 $513.76 $603.66 $514.69 $604.7639 $664.51 $780.80 $635.29 $746.46 $520.35 $611.42 $521.30 $612.5240 $672.94 $824.35 $643.34 $788.10 $526.95 $645.52 $527.90 $646.6841 $685.57 $839.83 $655.42 $802.90 $536.85 $657.64 $537.82 $658.8342 $697.69 $854.66 $667.00 $817.08 $546.33 $669.25 $547.32 $670.4743 $714.53 $875.31 $683.11 $836.81 $559.52 $685.42 $560.54 $686.6644 $735.60 $901.11 $703.25 $861.48 $576.02 $705.62 $577.06 $706.9045 $760.35 $931.42 $726.91 $890.46 $595.40 $729.36 $596.47 $730.6846 $789.83 $967.54 $755.10 $924.99 $618.49 $757.65 $619.61 $759.0247 $823.01 $1,008.18 $786.81 $963.84 $644.46 $789.47 $645.63 $790.9048 $860.92 $1,054.62 $823.06 $1,008.24 $674.15 $825.83 $675.37 $827.3349 $898.30 $1,100.42 $858.80 $1,052.03 $703.43 $861.70 $704.70 $863.2650 $940.43 $1,293.09 $899.07 $1,236.22 $736.41 $1,012.57 $737.74 $1,014.4051 $982.02 $1,350.28 $938.84 $1,290.90 $768.99 $1,057.36 $770.38 $1,059.2752 $1,027.83 $1,413.27 $982.63 $1,351.12 $804.86 $1,106.68 $806.31 $1,108.6853 $1,074.17 $1,476.99 $1,026.93 $1,412.03 $841.14 $1,156.57 $842.66 $1,158.6654 $1,124.19 $1,545.77 $1,074.76 $1,477.79 $880.31 $1,210.43 $881.91 $1,212.6255 $1,174.22 $1,614.55 $1,122.58 $1,543.55 $919.48 $1,264.29 $921.15 $1,266.5856 $1,228.45 $1,689.12 $1,174.43 $1,614.84 $961.95 $1,322.69 $963.69 $1,325.0857 $1,283.21 $1,764.42 $1,226.78 $1,686.82 $1,004.84 $1,381.65 $1,006.65 $1,384.1558 $1,341.66 $1,844.78 $1,282.66 $1,763.66 $1,050.60 $1,444.58 $1,052.51 $1,447.1959 $1,370.62 $1,884.61 $1,310.35 $1,801.73 $1,073.28 $1,475.76 $1,075.22 $1,478.4360 $1,429.07 $1,964.97 $1,366.22 $1,878.56 $1,119.05 $1,538.69 $1,121.07 $1,541.4861 $1,479.62 $2,034.48 $1,414.55 $1,945.01 $1,158.63 $1,593.12 $1,160.73 $1,596.0062 $1,512.79 $2,080.09 $1,446.26 $1,988.61 $1,184.61 $1,628.84 $1,186.75 $1,631.7963 $1,554.39 $2,137.29 $1,486.03 $2,043.29 $1,217.18 $1,673.63 $1,219.39 $1,676.6664+ $1,579.65 $2,172.04 $1,510.20 $2,076.52 $1,236.96 $1,700.84 $1,239.21 $1,703.92

$526.55 $503.40 $412.32 $413.07

$6,000


$1,50010%

Yes



8

$10/$20

00%

$4,000


$4,500




Yes


$00%

$35/$70$7,900

88

YesYes

$20/$400%$0


HMOOctober 1, 2019

33871PA0100021

December 31, 2019




Rate Pages









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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$264.04 $264.04 $261.14 $261.14 $199.81 $199.81 $286.53 $286.53$287.51 $287.51 $284.36 $284.36 $217.57 $217.57 $312.00 $312.00$296.48 $296.48 $293.23 $293.23 $224.36 $224.36 $321.74 $321.74$305.45 $305.45 $302.11 $302.11 $231.15 $231.15 $331.48 $331.48$315.12 $315.12 $311.66 $311.66 $238.47 $238.47 $341.96 $341.96$324.78 $324.78 $321.22 $321.22 $245.78 $245.78 $352.45 $352.45$334.79 $334.79 $331.12 $331.12 $253.35 $253.35 $363.31 $363.31$345.14 $388.29 $341.36 $384.03 $261.19 $293.84 $374.55 $421.37$345.14 $388.29 $341.36 $384.03 $261.19 $293.84 $374.55 $421.37$345.14 $388.29 $341.36 $384.03 $261.19 $293.84 $374.55 $421.37$345.14 $388.29 $341.36 $384.03 $261.19 $293.84 $374.55 $421.37$346.53 $389.84 $342.73 $385.57 $262.23 $295.01 $376.05 $423.05$353.43 $397.61 $349.56 $393.25 $267.46 $300.89 $383.54 $431.48$361.71 $406.93 $357.75 $402.47 $273.73 $307.94 $392.53 $441.59$375.17 $422.07 $371.06 $417.44 $283.91 $319.40 $407.14 $458.03$386.22 $434.49 $381.99 $429.73 $292.27 $328.81 $419.12 $471.51$391.74 $460.29 $387.45 $455.25 $296.45 $348.33 $425.11 $499.51$400.02 $470.03 $395.64 $464.88 $302.72 $355.70 $434.10 $510.07$408.31 $479.76 $403.83 $474.50 $308.99 $363.06 $443.09 $520.63$413.48 $485.84 $408.95 $480.52 $312.91 $367.66 $448.71 $527.23$419.01 $492.33 $414.42 $486.94 $317.08 $372.57 $454.70 $534.28$421.77 $495.58 $417.15 $490.15 $319.17 $375.03 $457.70 $537.80$424.53 $498.82 $419.88 $493.36 $321.26 $377.49 $460.70 $541.32$427.29 $502.06 $422.61 $496.56 $323.35 $379.94 $463.69 $544.84$430.05 $505.31 $425.34 $499.77 $325.44 $382.40 $466.69 $548.36$435.57 $511.80 $430.80 $506.19 $329.62 $387.31 $472.68 $555.40$441.10 $540.34 $436.26 $534.42 $333.80 $408.91 $478.67 $586.38$449.38 $550.49 $444.46 $544.46 $340.07 $416.59 $487.66 $597.39$457.32 $560.21 $452.31 $554.08 $346.08 $423.94 $496.28 $607.94$468.36 $573.74 $463.23 $567.46 $354.44 $434.18 $508.26 $622.62$482.17 $590.65 $476.88 $584.18 $364.88 $446.98 $523.25 $640.98$498.39 $610.53 $492.93 $603.84 $377.16 $462.02 $540.85 $662.54$517.72 $634.20 $512.05 $627.26 $391.79 $479.94 $561.82 $688.23$539.46 $660.84 $533.55 $653.60 $408.24 $500.09 $585.42 $717.14$564.31 $691.28 $558.13 $683.71 $427.05 $523.13 $612.39 $750.18$588.82 $721.30 $582.37 $713.40 $445.59 $545.85 $638.98 $782.75$616.43 $847.59 $609.68 $838.30 $466.49 $641.42 $668.95 $919.80$643.70 $885.08 $636.64 $875.38 $487.12 $669.79 $698.53 $960.48$673.72 $926.37 $666.34 $916.22 $509.84 $701.03 $731.12 $1,005.29$704.10 $968.13 $696.38 $957.52 $532.83 $732.64 $764.08 $1,050.61$736.88 $1,013.22 $728.81 $1,002.11 $557.64 $766.76 $799.66 $1,099.54$769.67 $1,058.30 $761.24 $1,046.71 $582.45 $800.87 $835.24 $1,148.46$805.22 $1,107.18 $796.40 $1,095.05 $609.36 $837.87 $873.82 $1,201.51$841.12 $1,156.54 $831.90 $1,143.87 $636.52 $875.22 $912.78 $1,255.07$879.43 $1,209.21 $869.79 $1,195.97 $665.51 $915.08 $954.35 $1,312.23$898.41 $1,235.32 $888.57 $1,221.78 $679.88 $934.83 $974.95 $1,340.56$936.72 $1,287.99 $926.46 $1,273.88 $708.87 $974.70 $1,016.53 $1,397.72$969.86 $1,333.55 $959.23 $1,318.94 $733.94 $1,009.17 $1,052.48 $1,447.16$991.60 $1,363.45 $980.74 $1,348.51 $750.40 $1,031.80 $1,076.08 $1,479.61

$1,018.87 $1,400.94 $1,007.70 $1,385.59 $771.03 $1,060.17 $1,105.67 $1,520.30$1,035.42 $1,423.72 $1,024.08 $1,408.12 $783.57 $1,077.41 $1,123.65 $1,545.02$345.14 $341.36 $261.19 $374.55

$4,25030%








$3,250 $6,850 $00%/20%/30%50% 50%


$7,900 $7,900Yes Yes



Rate Pages









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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$217.85 $217.85 $322.44 $322.44 $259.00 $259.00 $247.05 $247.05$237.22 $237.22 $351.10 $351.10 $282.02 $282.02 $269.01 $269.01$244.62 $244.62 $362.06 $362.06 $290.83 $290.83 $277.40 $277.40$252.03 $252.03 $373.02 $373.02 $299.63 $299.63 $285.80 $285.80$260.00 $260.00 $384.82 $384.82 $309.11 $309.11 $294.84 $294.84$267.97 $267.97 $396.62 $396.62 $318.59 $318.59 $303.89 $303.89$276.23 $276.23 $408.85 $408.85 $328.41 $328.41 $313.25 $313.25$284.78 $320.37 $421.49 $474.18 $338.56 $380.88 $322.94 $363.31$284.78 $320.37 $421.49 $474.18 $338.56 $380.88 $322.94 $363.31$284.78 $320.37 $421.49 $474.18 $338.56 $380.88 $322.94 $363.31$284.78 $320.37 $421.49 $474.18 $338.56 $380.88 $322.94 $363.31$285.91 $321.65 $423.18 $476.07 $339.92 $382.41 $324.23 $364.76$291.61 $328.06 $431.61 $485.56 $346.69 $390.02 $330.69 $372.03$298.44 $335.75 $441.72 $496.94 $354.81 $399.17 $338.44 $380.74$309.55 $348.24 $458.16 $515.43 $368.02 $414.02 $351.03 $394.91$318.66 $358.50 $471.65 $530.60 $378.85 $426.21 $361.37 $406.54$323.22 $379.78 $478.39 $562.11 $384.27 $451.52 $366.54 $430.68$330.05 $387.81 $488.51 $574.00 $392.39 $461.06 $374.29 $439.79$336.89 $395.84 $498.62 $585.88 $400.52 $470.61 $382.04 $448.89$341.16 $400.86 $504.95 $593.31 $405.60 $476.58 $386.88 $454.58$345.72 $406.22 $511.69 $601.24 $411.02 $482.94 $392.05 $460.66$348.00 $408.89 $515.06 $605.20 $413.72 $486.13 $394.63 $463.69$350.27 $411.57 $518.43 $609.16 $416.43 $489.31 $397.21 $466.73$352.55 $414.25 $521.81 $613.12 $419.14 $492.49 $399.80 $469.76$354.83 $416.93 $525.18 $617.08 $421.85 $495.67 $402.38 $472.80$359.39 $422.28 $531.92 $625.01 $427.27 $502.04 $407.55 $478.87$363.94 $445.83 $538.67 $659.87 $432.68 $530.04 $412.72 $505.58$370.78 $454.20 $548.78 $672.26 $440.81 $539.99 $420.47 $515.07$377.33 $462.23 $558.48 $684.13 $448.60 $549.53 $427.89 $524.17$386.44 $473.39 $571.96 $700.65 $459.43 $562.80 $438.23 $536.83$397.83 $487.34 $588.82 $721.31 $472.97 $579.39 $451.15 $552.65$411.22 $503.74 $608.63 $745.58 $488.88 $598.88 $466.32 $571.25$427.16 $523.27 $632.24 $774.49 $507.84 $622.11 $484.41 $593.40$445.10 $545.25 $658.79 $807.02 $529.17 $648.24 $504.75 $618.32$465.61 $570.37 $689.14 $844.19 $553.55 $678.10 $528.00 $646.81$485.83 $595.14 $719.06 $880.85 $577.59 $707.55 $550.93 $674.89$508.61 $699.34 $752.78 $1,035.08 $604.67 $831.43 $576.77 $793.06$531.11 $730.27 $786.08 $1,080.86 $631.42 $868.20 $602.28 $828.14$555.88 $764.34 $822.75 $1,131.28 $660.87 $908.70 $630.38 $866.77$580.94 $798.79 $859.84 $1,182.28 $690.67 $949.67 $658.79 $905.84$608.00 $835.99 $899.88 $1,237.34 $722.83 $993.89 $689.47 $948.03$635.05 $873.19 $939.92 $1,292.40 $755.00 $1,038.12 $720.15 $990.21$664.38 $913.52 $983.34 $1,352.09 $789.87 $1,086.07 $753.42 $1,035.95$694.00 $954.25 $1,027.17 $1,412.36 $825.08 $1,134.48 $787.00 $1,082.13$725.61 $997.71 $1,073.96 $1,476.69 $862.66 $1,186.16 $822.85 $1,131.42$741.27 $1,019.25 $1,097.14 $1,508.57 $881.28 $1,211.76 $840.61 $1,155.84$772.88 $1,062.71 $1,143.93 $1,572.90 $918.86 $1,263.43 $876.46 $1,205.13$800.22 $1,100.30 $1,184.39 $1,628.54 $951.36 $1,308.12 $907.46 $1,247.75$818.16 $1,124.97 $1,210.94 $1,665.05 $972.69 $1,337.45 $927.80 $1,275.73$840.66 $1,155.90 $1,244.24 $1,710.83 $999.44 $1,374.23 $953.31 $1,310.81$854.33 $1,174.70 $1,264.47 $1,738.65 $1,015.68 $1,396.57 $968.82 $1,332.12$284.78 $421.49 $338.56 $322.94







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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$363.33 $363.33 $421.01 $421.01 $402.50 $402.50 $329.10 $329.10$395.63 $395.63 $458.44 $458.44 $438.27 $438.27 $358.36 $358.36$407.98 $407.98 $472.75 $472.75 $451.95 $451.95 $369.54 $369.54$420.33 $420.33 $487.05 $487.05 $465.63 $465.63 $380.73 $380.73$433.62 $433.62 $502.46 $502.46 $480.37 $480.37 $392.77 $392.77$446.92 $446.92 $517.87 $517.87 $495.10 $495.10 $404.82 $404.82$460.70 $460.70 $533.83 $533.83 $510.36 $510.36 $417.30 $417.30$474.95 $534.31 $550.34 $619.14 $526.14 $591.91 $430.20 $483.98$474.95 $534.31 $550.34 $619.14 $526.14 $591.91 $430.20 $483.98$474.95 $534.31 $550.34 $619.14 $526.14 $591.91 $430.20 $483.98$474.95 $534.31 $550.34 $619.14 $526.14 $591.91 $430.20 $483.98$476.84 $536.45 $552.55 $621.61 $528.24 $594.27 $431.92 $485.91$486.34 $547.14 $563.55 $634.00 $538.77 $606.11 $440.53 $495.59$497.74 $559.96 $576.76 $648.86 $551.39 $620.32 $450.85 $507.21$516.27 $580.80 $598.22 $673.00 $571.91 $643.40 $467.63 $526.08$531.46 $597.90 $615.84 $692.81 $588.75 $662.34 $481.40 $541.57$539.06 $633.40 $624.64 $733.95 $597.17 $701.67 $488.28 $573.73$550.46 $646.79 $637.85 $749.47 $609.80 $716.51 $498.60 $585.86$561.86 $660.19 $651.06 $764.99 $622.42 $731.35 $508.93 $597.99$568.98 $668.56 $659.31 $774.69 $630.32 $740.62 $515.38 $605.57$576.58 $677.49 $668.12 $785.04 $638.73 $750.51 $522.26 $613.66$580.38 $681.95 $672.52 $790.21 $642.94 $755.46 $525.71 $617.70$584.18 $686.41 $676.92 $795.39 $647.15 $760.40 $529.15 $621.75$587.98 $690.88 $681.33 $800.56 $651.36 $765.35 $532.59 $625.79$591.78 $695.34 $685.73 $805.73 $655.57 $770.29 $536.03 $629.84$599.38 $704.27 $694.53 $816.08 $663.99 $780.19 $542.91 $637.92$606.98 $743.55 $703.34 $861.59 $672.41 $823.70 $549.80 $673.50$618.38 $757.51 $716.55 $877.77 $685.03 $839.17 $560.12 $686.15$629.30 $770.90 $729.21 $893.28 $697.13 $853.99 $570.02 $698.27$644.50 $789.51 $746.82 $914.85 $713.97 $874.61 $583.78 $715.13$663.50 $812.79 $768.83 $941.82 $735.02 $900.40 $600.99 $736.21$685.82 $840.13 $794.70 $973.50 $759.75 $930.69 $621.21 $760.98$712.42 $872.71 $825.52 $1,011.26 $789.21 $966.78 $645.30 $790.49$742.34 $909.37 $860.19 $1,053.73 $822.36 $1,007.39 $672.40 $823.70$776.54 $951.26 $899.81 $1,102.27 $860.24 $1,053.79 $703.38 $861.64$810.26 $992.56 $938.89 $1,150.14 $897.59 $1,099.55 $733.92 $899.06$848.25 $1,166.35 $982.91 $1,351.51 $939.69 $1,292.07 $768.34 $1,056.47$885.77 $1,217.94 $1,026.39 $1,411.29 $981.25 $1,349.22 $802.33 $1,103.20$927.09 $1,274.75 $1,074.27 $1,477.12 $1,027.02 $1,412.16 $839.75 $1,154.66$968.89 $1,332.22 $1,122.70 $1,543.72 $1,073.32 $1,475.82 $877.61 $1,206.71

$1,014.01 $1,394.26 $1,174.99 $1,615.60 $1,123.31 $1,544.55 $918.48 $1,262.91$1,059.13 $1,456.30 $1,227.27 $1,687.49 $1,173.29 $1,613.28 $959.35 $1,319.10$1,108.05 $1,523.56 $1,283.95 $1,765.44 $1,227.48 $1,687.79 $1,003.66 $1,380.03$1,157.44 $1,591.48 $1,341.19 $1,844.14 $1,282.20 $1,763.03 $1,048.40 $1,441.55$1,210.16 $1,663.97 $1,402.28 $1,928.13 $1,340.60 $1,843.33 $1,096.15 $1,507.21$1,236.28 $1,699.89 $1,432.55 $1,969.75 $1,369.54 $1,883.12 $1,119.81 $1,539.74$1,289.00 $1,772.38 $1,493.63 $2,053.75 $1,427.94 $1,963.42 $1,167.57 $1,605.40$1,334.60 $1,835.07 $1,546.47 $2,126.39 $1,478.45 $2,032.87 $1,208.87 $1,662.19$1,364.52 $1,876.21 $1,581.14 $2,174.07 $1,511.60 $2,078.45 $1,235.97 $1,699.46$1,402.04 $1,927.80 $1,624.62 $2,233.85 $1,553.16 $2,135.60 $1,269.95 $1,746.19$1,424.84 $1,959.15 $1,651.02 $2,270.17 $1,578.42 $2,170.33 $1,290.60 $1,774.58$474.95 $550.34 $526.14 $430.20




$0 $0 $0$00% 0% 0% 0%

$10/$20 $20/$40 $35/$70$30/$60$5,000 $4,000 $4,500 $7,900

Yes Yes YesYes



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Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco Non‐Tobacco Tobacco$329.02 $329.02 $276.14 $276.14 $272.69 $272.69 $208.15 $208.15$358.27 $358.27 $300.69 $300.69 $296.93 $296.93 $226.65 $226.65$369.45 $369.45 $310.08 $310.08 $306.20 $306.20 $233.73 $233.73$380.63 $380.63 $319.46 $319.46 $315.47 $315.47 $240.80 $240.80$392.67 $392.67 $329.57 $329.57 $325.45 $325.45 $248.42 $248.42$404.72 $404.72 $339.68 $339.68 $335.43 $335.43 $256.04 $256.04$417.19 $417.19 $350.14 $350.14 $345.77 $345.77 $263.93 $263.93$430.09 $483.85 $360.97 $406.09 $356.46 $401.02 $272.09 $306.11$430.09 $483.85 $360.97 $406.09 $356.46 $401.02 $272.09 $306.11$430.09 $483.85 $360.97 $406.09 $356.46 $401.02 $272.09 $306.11$430.09 $483.85 $360.97 $406.09 $356.46 $401.02 $272.09 $306.11$431.81 $485.79 $362.42 $407.72 $357.89 $402.62 $273.18 $307.33$440.42 $495.47 $369.64 $415.84 $365.02 $410.64 $278.62 $313.45$450.74 $507.08 $378.30 $425.59 $373.57 $420.27 $285.15 $320.80$467.51 $525.95 $392.38 $441.42 $387.47 $435.91 $295.77 $332.74$481.27 $541.43 $403.93 $454.42 $398.88 $448.74 $304.47 $342.53$488.16 $573.58 $409.70 $481.40 $404.58 $475.38 $308.83 $362.87$498.48 $585.71 $418.37 $491.58 $413.14 $485.44 $315.36 $370.54$508.80 $597.84 $427.03 $501.76 $421.69 $495.49 $321.89 $378.22$515.25 $605.42 $432.45 $508.12 $427.04 $501.77 $325.97 $383.01$522.13 $613.51 $438.22 $514.91 $432.74 $508.47 $330.32 $388.13$525.57 $617.55 $441.11 $518.30 $435.59 $511.82 $332.50 $390.69$529.01 $621.59 $444.00 $521.70 $438.45 $515.17 $334.68 $393.24$532.46 $625.63 $446.88 $525.09 $441.30 $518.53 $336.85 $395.80$535.90 $629.68 $449.77 $528.48 $444.15 $521.88 $339.03 $398.36$542.78 $637.76 $455.55 $535.27 $449.85 $528.58 $343.38 $403.47$549.66 $673.33 $461.32 $565.12 $455.56 $558.06 $347.74 $425.98$559.98 $685.98 $469.99 $575.73 $464.11 $568.54 $354.27 $433.98$569.87 $698.09 $478.29 $585.90 $472.31 $578.58 $360.52 $441.64$583.64 $714.95 $489.84 $600.05 $483.72 $592.55 $369.23 $452.31$600.84 $736.03 $504.28 $617.74 $497.98 $610.02 $380.12 $465.64$621.05 $760.79 $521.24 $638.53 $514.73 $630.54 $392.90 $481.31$645.14 $790.30 $541.46 $663.29 $534.69 $655.00 $408.14 $499.97$672.24 $823.49 $564.20 $691.15 $557.15 $682.51 $425.28 $520.97$703.20 $861.42 $590.19 $722.98 $582.81 $713.95 $444.87 $544.97$733.74 $898.83 $615.82 $754.38 $608.12 $744.95 $464.19 $568.64$768.15 $1,056.20 $644.70 $886.46 $636.64 $875.38 $485.96 $668.20$802.12 $1,102.92 $673.21 $925.67 $664.80 $914.10 $507.46 $697.75$839.54 $1,154.37 $704.62 $968.85 $695.81 $956.74 $531.13 $730.30$877.39 $1,206.41 $736.38 $1,012.53 $727.18 $999.87 $555.07 $763.22$918.25 $1,262.59 $770.68 $1,059.68 $761.04 $1,046.43 $580.92 $798.77$959.11 $1,318.77 $804.97 $1,106.83 $794.91 $1,093.00 $606.77 $834.31

$1,003.41 $1,379.68 $842.15 $1,157.96 $831.62 $1,143.48 $634.80 $872.84$1,048.14 $1,441.19 $879.69 $1,209.58 $868.69 $1,194.45 $663.09 $911.75$1,095.88 $1,506.83 $919.76 $1,264.67 $908.26 $1,248.86 $693.30 $953.28$1,119.53 $1,539.36 $939.61 $1,291.97 $927.87 $1,275.82 $708.26 $973.86$1,167.27 $1,605.00 $979.68 $1,347.06 $967.43 $1,330.22 $738.46 $1,015.39$1,208.56 $1,661.77 $1,014.33 $1,394.71 $1,001.65 $1,377.27 $764.58 $1,051.30$1,235.66 $1,699.03 $1,037.08 $1,425.98 $1,024.11 $1,408.15 $781.73 $1,074.87$1,269.63 $1,745.75 $1,065.59 $1,465.19 $1,052.27 $1,446.87 $803.22 $1,104.43$1,290.27 $1,774.13 $1,082.91 $1,489.01 $1,069.38 $1,470.40 $816.27 $1,122.39$430.09 $360.97 $356.46 $272.09







Plan Design Summary























Plan Design Summary



Rates by County


RATING AREA 827,377 16,768 16,060 31,650 22,510






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4950

A B C D E F G H I J K L M N O P Q R S T U V W X YAc Unified Rate Review v4.3

Company Legal Name: KHPE State: PAHIOS Issuer ID: 33871 Market: Small GroupEffective Date of Rate Change(s): 1/1/2019

Market Level Calculations (Same for all Plans)

Section I: Experience period dataExperience Period: 1/1/2017 to 12/31/2017

Experience Period Aggregate Amount PMPM % of Prem

Premiums (net of MLR Rebate) in Experience Period: 700,305,217.00$ $490.00 100.00%Incurred Claims in Experience Period 451,358,874.00$ 315.81 64.45%Allowed Claims: 540,237,359.00$ 378.00 77.14%Index Rate of Experience Period 378.00$ Experience Period Member Months 1,429,195

Section II: Allowed Claims, PMPM basisExperience Period Projection Period: 1/1/2019 to 12/31/2019 Mid‐point to Mid‐point, Experience to Projection: 24 months

on Actual Experience AllowedAdj't. from Experience to

Projection Period Projections, before credibility Adjustment Credibility Manual

Benefit CategoryUtilization Description

Utilization per 1,000

Average Cost/Service PMPM

Pop'l risk Morbidity Other Cost Util





Inpatient Hospital Admits 62.12 $10,605.55 $54.90 1.000 1.012 1.038 1.015 63.98 $11,573.21 $61.71 0.00 $0.00 $0.00Outpatient Hospital Services 1,798.53 $381.46 57.17 1.000 1.012 1.035 1.015 1,852.57 413.99 63.91 0.00 0.00 0.00Professional Services 8,521.41 $86.82 61.65 1.000 1.012 1.013 1.015 8,777.47 90.14 65.93 0.00 0.00 0.00Other Medical Services 0.14 $113.23 0.00 1.000 1.012 1.013 1.015 0.15 117.55 0.00 0.00 0.00 0.00Capitation Services 12,000.00 84.09 84.09 1.000 1.012 1.150 1.000 12,000.00 112.57 112.57 0.00 0.00 0.00Prescription Drug Prescriptions 11,478.84 125.64 120.19 1.000 1.012 1.030 1.016 11,850.35 134.92 133.24 0.00 0.00 0.00Total $378.00 $437.36 $0.00

After Credibility Projected Period TotalsSection III: Projected Experience: Projected Allowed Claims PMPM (w/applied credibility if applicable) 100.00% 0.00% $437.36 $600,219,763

Paid to Allowed Average Factor in Projection Period 0.848Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $370.79 $508,863,113Projected Risk Adjustments PMPM ‐70.57 (96,845,450) Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $441.36 $605,708,563Projected ACA reinsurance recoveries, net of rein prem, PMPM 0.00 0

Projected Incurred Claims $441.36 $605,708,563

Administrative Expense Load 14.55% 77.43 106,260,596Profit & Risk Load 2.00% 10.64 14,607,492Taxes & Fees 0.52% 2.77 3,797,948Single Risk Pool Gross Premium Avg. Rate, PMPM $532.20 $730,374,599Index Rate for Projection Period 437.36$

% increase over Experience Period 8.61%% Increase, annualized: 4.22%

Projected Member Months 1,372,380

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.

Annualized Trend Factors

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Product‐Plan Data Collection

Company Legal Name: KHPE State: PAHIOS Issuer ID: 33871 Market: Small GroupEffective Date of Rate Change(s):

Product/Plan Level Calculations

Section I: General Product and Plan InformationProductProduct ID:Metal: Platinum Platinum Gold Silver Bronze Gold Silver Platinum Platinum Gold Gold Silver Silver Bronze Gold Silver Gold Silver Gold SilverAV Metal Value 0.92 0.896 0.819 0.714 0.635 0.767 0.719 0.92 0.896 0.819 0.811 0.719 0.714 0.635 0.808 0.718 0.767 0.719 0.808 0.717AV Pricing Value 0.974 0.964 0.869 0.757 0.685 0.871 0.768 1.167 1.116 0.914 0.916 0.765 0.757 0.579 0.854 0.744 0.83 0.631 0.934 0.75Plan Category Terminated Terminated Terminated Terminated Terminated Terminated Terminated Renewing Renewing Renewing Renewing Renewing Renewing Renewing Terminated Terminated Renewing Renewing Renewing RenewingPlan Type: HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO

Plan NamePlatinum Preferred

$10/$20/$100

Platinum Preferred

$20/$40/$150

Keystone HMO Gold Preferred $30/$60/$600

Silver Classic $3,250/$30/$60/5

0%

Bronze Essential $6,850/$50/$100/

$700Keystone HMO Gold Proactive

Keystone HMO Silver Proactive

Platinum Preferred

$10/$20/$150

Platinum Preferred

$20/$40/$200

Keystone HMO Gold Preferred $35/$70/$650

Gold Classic $1,500/$25/$50/9

0%


0%


0%


$700

Gold Classic $2,000

$40/$80/100%

Silver Secure $4,500/$40/$80/$

600Keystone HMO Gold Proactive

Keystone HMO Silver Proactive

Gold Classic $2,500/$40/$80/1

00%


00%Plan ID (Standard Component ID): 33871PA0100001 33871PA0100002 33871PA0100003 33871PA0100006 33871PA0100007 33871PA0100008 33871PA0100009 33871PA0100020 33871PA0100021 33871PA0100022 33871PA0100023 33871PA0100024 33871PA0100025 33871PA0100026 33871PA0100035 33871PA0100037 33871PA0100044 33871PA0100045 33871PA0100047 33871PA0100048Exchange Plan? Yes Yes Yes Yes Yes Yes Yes No No No No No No No Yes Yes No No No NoHistorical Rate Increase ‐ Calendar Year ‐ 2Historical Rate Increase ‐ Calendar Year ‐ 1Historical Rate Increase ‐ Calendar Year 0Effective Date of Proposed Rates 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019Rate Change % (over prior filing) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 4.43% 4.44% 3.88% 0.62% 3.19% 3.59% 4.77% 0.00% 0.00% 5.33% 5.10% 3.28% 4.28%Cum'tive Rate Change % (over 12 mos prior) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 4.43% 4.44% 3.88% 0.62% 3.19% 3.59% 4.77% 0.00% 0.00% 5.33% 5.10% 3.28% 4.28%Proj'd Per Rate Change % (over Exper. Period) ‐100.00% ‐100.00% ‐100.00% ‐100.00% ‐100.00% ‐100.00% ‐100.00% 14.50% 14.94% 11.95% 8.53% 1.96% 4.38% 9.01% ‐100.00% ‐100.00% 18.10% 6.28% 28.79% ‐6.09%Product Rate Increase %

Section II: Components of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM)

Plan ID (Standard Component ID): Total 33871PA0100001 33871PA0100002 33871PA0100003 33871PA0100006 33871PA0100007 33871PA0100008 33871PA0100009 33871PA0100020 33871PA0100021 33871PA0100022 33871PA0100023 33871PA0100024 33871PA0100025 33871PA0100026 33871PA0100035 33871PA0100037 33871PA0100044 33871PA0100045 33871PA0100047 33871PA0100048Inpatient $2.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.73 $3.49 $2.53 $0.42 $1.86 $2.07 $2.03 $0.00 $0.00 $3.04 $2.37 $2.20 $2.26Outpatient $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.86 $3.62 $2.62 $0.43 $1.93 $2.14 $2.10 $0.00 $0.00 $3.15 $2.46 $2.28 $2.35Professional $2.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.98 $3.73 $2.70 $0.45 $1.99 $2.21 $2.16 $0.00 $0.00 $3.25 $2.53 $2.35 $2.42Prescription Drug $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.05 $7.54 $5.45 $0.90 $4.03 $4.46 $4.37 $0.00 $0.00 $6.56 $5.12 $4.76 $4.89Other $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 $0.00Capitation $4.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.80 $6.37 $4.61 $0.76 $3.40 $3.77 $3.69 $0.00 $0.00 $5.54 $4.32 $4.02 $4.13Administration $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.64 $4.34 $3.14 $0.52 $2.32 $2.57 $2.52 $0.00 $0.00 $3.78 $2.95 $2.74 $2.82Taxes & Fees $0.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.17 $0.16 $0.11 $0.02 $0.08 $0.09 $0.09 $0.00 $0.00 $0.14 $0.11 $0.10 $0.10Risk & Profit Charge $0.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.64 $0.60 $0.43 $0.07 $0.32 $0.35 $0.35 $0.00 $0.00 $0.52 $0.41 $0.38 $0.39Total Rate Increase $22.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.86 $29.86 $21.59 $3.58 $15.93 $17.67 $17.31 $0.00 $0.00 $25.98 $20.26 $18.82 $19.36Member Cost Share Increase $3.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.66 $3.42 $5.18 $20.13 $6.77 $5.42 $0.62 $0.00 $0.00 ‐$0.83 $0.00 $8.28 $2.68

Average Current Rate PMPM $523.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $718.83 $672.93 $555.85 $579.12 $498.97 $491.78 $363.01 $0.00 $0.00 $487.00 $397.32 $574.23 $451.73Projected Member Months 1,372,380 0 0 0 0 0 0 0 27,312 87,696 296,856 13,824 32,604 16,980 26,976 0 0 164,340 353,460 8,100 15,600

Section III: Experience Period Information

Plan ID (Standard Component ID): Total 33871PA0100001 33871PA0100002 33871PA0100003 33871PA0100006 33871PA0100007 33871PA0100008 33871PA0100009 33871PA0100020 33871PA0100021 33871PA0100022 33871PA0100023 33871PA0100024 33871PA0100025 33871PA0100026 33871PA0100035 33871PA0100037 33871PA0100044 33871PA0100045 33871PA0100047 33871PA0100048Plan Adjusted Index Rate $490.00 $579.67 $629.16 $522.07 $323.71 $276.41 $403.70 $313.19 $636.79 $606.47 $510.00 $527.03 $468.74 $452.87 $331.77 $459.52 $317.94 $439.14 $371.02 $453.18 $499.23Member Months 1,429,195 130 227 408 95 220 668 4,853 31,479 104,237 331,229 15,296 40,654 19,617 27,221 60 32 164,746 293,144 29,001 69Total Premium (TP) $700,305,217 $75,357 $142,820 $213,003 $30,752 $60,811 $269,672 $1,519,894 $20,045,566 $63,216,243 $168,928,395 $8,061,395 $19,056,228 $8,883,948 $9,031,115 $27,571 $10,174 $72,347,228 $108,762,682 $13,142,811 $34,447

EHB Percent of TP, [see instructions] 99.09% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 98.94% 98.94% 98.94% 99.34% 99.34% 98.94% 98.94% 98.94% 98.94% state mandated benefits portion of TP that are other than EHB 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% Other benefits portion of TP 0.91% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 1.06% 1.06% 1.06% 0.66% 0.66% 1.06% 1.06% 1.06% 1.06% Total Allowed Claims (TAC) $532,221,462 $37,822.92 $85,192.26 $256,900.93 $31,461.84 $24,056.33 $141,158.92 $984,914.01 $15,938,249.55 $47,006,085.42 $134,596,397.45 $5,980,489.72 $13,845,371.77 $6,880,383.58 $4,877,677.63 $15,136.27 $6,000.78 $52,718,826.23 $79,792,261.68 $10,610,526.35 $25,657.56

EHB Percent of TAC, [see instructions] 99.09% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 98.94% 98.94% 98.94% 99.34% 99.34% 98.94% 98.94% 98.94% 98.94% state mandated benefits portion of TAC that are other than EHB 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% Other benefits portion of TAC 0.91% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 1.06% 1.06% 1.06% 0.66% 0.66% 1.06% 1.06% 1.06% 1.06% Allowed Claims which are not the issuer's obligation: $86,624,033 $6,910.66 $14,139.43 $34,513.89 $14,041.59 $16,205.69 $40,584.38 $283,977.61 $2,057,634.61 $6,730,566.08 $24,421,620.94 $166,744.33 $377,066.05 $1,877,950.58 $2,160,932.21 $8,845.44 $2,937.08 $11,686,609.24 $21,074,522.95 $799,064.58 $6,467.82

Portion of above payable by HHS's funds on behalf of insured person, in dollars $0 $0 $0 $0 $0 $0 $0 $0 $0 $0Portion of above payable by HHS on behalf of insured person, as % 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Total Incurred claims, payable with issuer funds $445,597,429 $30,912 $71,053 $222,387 $17,420 $7,851 $100,575 $700,936 $13,880,615 $40,275,519 $110,174,777 $5,813,745 $13,468,306 $5,002,433 $2,716,745 $6,291 $3,064 $41,032,217 $58,717,739 $9,811,462 $19,190

Net Amt of Rein $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 Risk Adjustment Transfer Amount ‐$54,176,450.98 ‐$44,505.24 $25,288.69 ‐$111,148.60 ‐$5,924.48 ‐$41,821.75 $10,562.90 ‐$76,500.96 $4,979,043.45 $5,401,901.98 ‐$11,353,918.24 ‐$1,606,658.94 ‐$3,165,578.76 ‐$280,888.36 ‐$2,962,949.87 $367.24 ‐$10,108.37 ‐$13,019,445.55 ‐$26,067,521.74 ‐$1,411,312.90 ‐$10,847.22

Incurred Claims PMPM $311.78 $237.79 $313.01 $545.07 $183.37 $35.68 $150.56 $144.43 $440.95 $386.38 $332.62 $380.08 $331.29 $255.00 $99.80 $104.85 $95.74 $249.06 $200.30 $338.31 $278.11Allowed Claims PMPM $372.39 $290.95 $375.30 $629.66 $331.18 $109.35 $211.32 $202.95 $506.31 $450.95 $406.35 $390.98 $340.57 $350.74 $179.19 $252.27 $187.52 $320.00 $272.19 $365.87 $371.85EHB portion of Allowed Claims, PMPM $369.02 $289.03 $372.82 $625.50 $328.99 $108.63 $209.92 $201.61 $502.97 $447.98 $403.67 $388.40 $336.96 $347.02 $177.29 $250.61 $186.29 $316.61 $269.31 $361.99 $367.91

Keystone HMO Small Group33871PA010

0.00%0.00%4.26%

4.44%

Claims Inform

ation

1/1/2019

Prem

ium In

form

ation

Section IV: Projected (12 months following effective date)

Plan ID (Standard Component ID): Total 33871PA0100001 33871PA0100002 33871PA0100003 33871PA0100006 33871PA0100007 33871PA0100008 33871PA0100009 33871PA0100020 33871PA0100021 33871PA0100022 33871PA0100023 33871PA0100024 33871PA0100025 33871PA0100026 33871PA0100035 33871PA0100037 33871PA0100044 33871PA0100045 33871PA0100047 33871PA0100048Plan Adjusted Index Rate $536.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $729.13 $697.06 $570.95 $571.98 $477.93 $472.69 $361.67 $0.00 $0.00 $518.64 $394.33 $583.64 $468.81Member Months 1,372,380 ‐ ‐ ‐ ‐ ‐ ‐ ‐ 27,312 87,696 296,856 13,824 32,604 16,980 26,976 ‐ ‐ 164,340 353,460 8,100 15,600 Total Premium (TP) $736,213,189 $0 $0 $0 $0 $0 $0 $0 $19,913,912 $61,129,540 $169,490,269 $7,907,115 $15,582,307 $8,026,277 $9,756,497 $0 $0 $85,233,791 $139,380,552 $4,727,514 $7,313,472

EHB Percent of TP, [see instructions] 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% state mandated benefits portion of TP that are other than EHB 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% Other benefits portion of TP 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% Total Allowed Claims (TAC) $594,773,578 $0 $0 $0 $0 $0 $0 $0 $14,285,640 $44,307,390 $136,278,412 $6,640,439 $14,250,840 $7,408,331 $9,951,887 $0 $0 $68,374,745 $126,806,942 $3,867,916 $6,886,868

EHB Percent of TAC, [see instructions] 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% state mandated benefits portion of TAC that are other than EHB 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% Other benefits portion of TAC 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20%

Allowed Claims which are not the issuer's obligation $124,805,746 $0 $0 $0 $0 $0 $0 $0 $1,680,178 $5,443,424 $27,774,903 $1,644,311 $4,290,623 $2,280,179 $3,485,592 $0 $0 $12,712,043 $33,201,688 $869,308 $2,236,025Portion of above payable by HHS's funds on behalf of insured person, in dollars $0 $0 $0 $0 $0 $0 $0 $0 $0 $0Portion of above payable by HHS on behalf of insured person, as % 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Total Incurred claims, payable with issuer funds $469,967,832 $0 $0 $0 $0 $0 $0 $0 $12,605,462 $38,863,966 $108,503,509 $4,996,128 $9,960,217 $5,128,151 $6,466,295 $0 $0 $55,662,702 $93,605,254 $2,998,607 $4,650,844

Net Amt of Rein $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Risk Adjustment Transfer Amount ‐$96,845,450 $0 $0 $0 $0 $0 $0 $0 ‐$1,927,340 ‐$6,188,489 ‐$20,948,391 ‐$975,525 ‐$2,300,783 ‐$1,198,236 ‐$1,903,629 $0 $0 ‐$11,597,066 ‐$24,942,795 ‐$571,597 ‐$1,100,853

Incurred Claims PMPM $342.45 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $461.54 $443.17 $365.51 $361.41 $305.49 $302.01 $239.71 #DIV/0! #DIV/0! $338.70 $264.83 $370.20 $298.13Allowed Claims PMPM $433.39 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $523.05 $505.24 $459.07 $480.36 $437.09 $436.30 $368.92 #DIV/0! #DIV/0! $416.06 $358.76 $477.52 $441.47EHB portion of Allowed Claims, PMPM $432.52 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $522.01 $504.23 $458.15 $479.40 $436.21 $435.42 $368.18 #DIV/0! #DIV/0! $415.22 $358.04 $476.57 $440.58

Prem

ium In

form

ation

Claims Inform

ation

Silver Platinum Gold Gold Gold Silver Silver Bronze Platinum Platinum Gold Gold Gold Silver Silver Silver Silver Bronze0.718 0.866 0.819 0.811 0.818 0.719 0.693 0.635 0.92 0.895 0.819 0.811 0.818 0.719 0.719 0.717 0.714 0.6350.716 1.053 0.868 0.832 0.856 0.765 0.749 0.684 1.22 1.166 0.954 0.953 0.86 0.8 0.749 0.76 0.79 0.603

Renewing Renewing Terminated Terminated Terminated Terminated Terminated Terminated Renewing Renewing Renewing Renewing Terminated Renewing Terminated Terminated Renewing RenewingHMO HMO POS POS POS POS POS POS POS POS POS POS POS POS POS POS POS POS

Silver Secure $5,000/$40/$80/$

600

Platinum Preferred

$30/$60/$400

Keystone DPOS Gold Preferred $30/$60/$600

Gold Classic $1,000

$25/$50/90%

Gold Classic $2,000

$40/$80/100%


0%

Silver Secure $3,500

$40/$80/$600

$6,850/$50/$100/$700

Platinum Preferred

$10/$20/$150

Platinum Preferred

$20/$40/$200

Keystone DPOS Gold Preferred $35/$70/$650

Gold Classic $1,500/$25/$50/9

0%

Gold Classic $2,000

$40/$80/100%


0%

Silver Secure $3,500

$40/$80/$600

Silver Classic $4,250

$40/$80/100%


0%


$70033871PA0100049 33871PA0100050 33871PA0110003 33871PA0110004 33871PA0110005 33871PA0110006 33871PA0110007 33871PA0110010 33871PA0110011 33871PA0110012 33871PA0110013 33871PA0110014 33871PA0110015 33871PA0110016 33871PA0110017 33871PA0110018 33871PA0110019 33871PA0110020

No No Yes Yes Yes Yes Yes Yes No No No No No No No No No No

1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/2019 1/1/20193.17% 4.67% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 4.33% 4.33% 3.76% 0.62% 0.00% 3.33% 0.00% 0.00% 3.59% 4.62%3.17% 4.67% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 4.33% 4.33% 3.76% 0.62% 0.00% 3.33% 0.00% 0.00% 3.59% 4.62%

#DIV/0! #DIV/0! ‐100.00% ‐100.00% ‐100.00% ‐100.00% ‐100.00% ‐100.00% 15.99% 14.85% 15.77% 6.70% ‐100.00% 3.65% ‐100.00% ‐100.00% 4.79% 6.01%

33871PA0100049 33871PA0100050 33871PA0110003 33871PA0110004 33871PA0110005 33871PA0110006 33871PA0110007 33871PA0110010 33871PA0110011 33871PA0110012 33871PA0110013 33871PA0110014 33871PA0110015 33871PA0110016 33871PA0110017 33871PA0110018 33871PA0110019 33871PA0110020$1.74 $3.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.67 $3.54 $2.48 $0.43 $0.00 $2.02 $0.00 $0.00 $2.10 $2.00$1.80 $3.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.80 $3.66 $2.57 $0.45 $0.00 $2.09 $0.00 $0.00 $2.18 $2.07$1.86 $4.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.92 $3.78 $2.65 $0.46 $0.00 $2.16 $0.00 $0.00 $2.24 $2.14$3.76 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.92 $7.64 $5.35 $0.93 $0.00 $4.37 $0.00 $0.00 $4.54 $4.32$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$3.18 $7.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.69 $6.45 $4.52 $0.79 $0.00 $3.69 $0.00 $0.00 $3.83 $3.65$2.16 $4.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.56 $4.40 $3.08 $0.54 $0.00 $2.51 $0.00 $0.00 $2.61 $2.49$0.08 $0.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.16 $0.16 $0.11 $0.02 $0.00 $0.09 $0.00 $0.00 $0.09 $0.09$0.30 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.63 $0.60 $0.42 $0.07 $0.00 $0.35 $0.00 $0.00 $0.36 $0.34

$14.88 $32.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.35 $30.24 $21.17 $3.69 $0.00 $17.28 $0.00 $0.00 $17.95 $17.09$6.76 $2.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.69 $3.55 $5.25 $20.78 $0.00 $7.04 $0.00 $0.00 $5.51 $0.63

$469.05 $705.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $724.78 $698.57 $562.44 $597.76 $0.00 $519.15 $0.00 $0.00 $499.55 $370.2110,164 1,776 0 0 0 0 0 0 38,124 88,368 119,952 31,272 0 17,064 0 0 14,892 7,020

33871PA0100049 33871PA0100050 33871PA0110003 33871PA0110004 33871PA0110005 33871PA0110006 33871PA0110007 33871PA0110010 33871PA0110011 33871PA0110012 33871PA0110013 33871PA0110014 33871PA0110015 33871PA0110016 33871PA0110017 33871PA0110018 33871PA0110019 33871PA0110020$0.00 $0.00 $667.91 $639.98 $369.08 $337.81 $564.66 $291.71 $657.01 $634.37 $514.56 $558.17 $545.00 $482.22 $427.41 $445.57 $471.02 $355.42

0 0 69 24 24 14 3 201 47,673 106,170 132,620 17,340 17,454 25,901 2,362 1,463 7,809 6,682$0 $0 $46,086 $15,360 $8,858 $4,729 $1,694 $58,635 $31,321,569 $67,350,895 $68,241,541 $9,678,707 $9,512,500 $12,490,053 $1,009,542 $651,875 $3,678,159 $2,374,902

98.94% 98.94% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94%

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%1.06% 1.06% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06%$0.00 $0.00 $21,800.31 $3,697.43 $1,889.31 $1,497.77 $81.06 $10,721.01 $24,213,062.45 $51,695,734.86 $50,771,129.97 $7,476,846.08 $7,689,903.36 $9,473,001.16 $508,517.56 $555,036.44 $2,890,462.92 $3,053,509.57

98.94% 100.00% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94% 98.94%

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%1.06% 0.00% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06% 1.06%

$0.00 $0.00 $6,219.65 $1,071.99 $340.45 $400.36 $32.32 $3,123.36 $599,135.84 $3,836,883.96 $5,122,467.76 $1,688,387.42 $1,178,076.63 $1,062,344.01 $95,938.66 $16,846.35 $882,330.72 $349,098.43

$0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00%$0 $0 $15,581 $2,625 $1,549 $1,097 $49 $7,598 $23,613,927 $47,858,851 $45,648,662 $5,788,459 $6,511,827 $8,410,657 $412,579 $538,190 $2,008,132 $2,704,411

$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 ‐$14,863.05 ‐$4,403.39 $4,275.47 ‐$453.47 ‐$1,498.20 ‐$22,826.83 $2,636,890.19 $4,725,430.90 ‐$5,967,842.98 ‐$731,035.25 ‐$1,096,781.11 ‐$2,514,301.56 ‐$94,627.64 $3,752.35 ‐$789,431.70 ‐$556,767.99

#DIV/0! #DIV/0! $225.81 $109.39 $64.54 $78.39 $16.24 $37.80 $495.33 $450.78 $344.21 $333.82 $373.09 $324.72 $174.67 $367.87 $257.16 $404.73#DIV/0! #DIV/0! $315.95 $154.06 $78.72 $106.98 $27.02 $53.34 $507.90 $486.91 $382.83 $431.19 $440.58 $365.74 $215.29 $379.38 $370.15 $456.98#DIV/0! #DIV/0! $313.86 $153.04 $78.20 $106.28 $26.84 $52.99 $502.52 $481.75 $378.77 $426.62 $435.91 $361.86 $213.01 $375.36 $366.22 $452.13

3.70%

Keystone DPOS Small Group33871PA011

0.00%0.00%4.26%

33871PA0100049 33871PA0100050 33871PA0110003 33871PA0110004 33871PA0110005 33871PA0110006 33871PA0110007 33871PA0110010 33871PA0110011 33871PA0110012 33871PA0110013 33871PA0110014 33871PA0110015 33871PA0110016 33871PA0110017 33871PA0110018 33871PA0110019 33871PA0110020$447.18 $657.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $762.07 $728.55 $595.70 $595.56 $0.00 $499.84 $0.00 $0.00 $493.60 $376.7710,164 1,776 ‐ ‐ ‐ ‐ ‐ ‐ 38,124 88,368 119,952 31,272 ‐ 17,064 ‐ ‐ 14,892 7,020

$4,545,107 $1,168,008 $0 $0 $0 $0 $0 $0 $29,053,101 $64,380,664 $71,455,974 $18,624,197 $0 $8,529,333 $0 $0 $7,350,618 $2,644,941

99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80%

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%0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20%

$3,596,438 $771,630 $0 $0 $0 $0 $0 $0 $19,961,390 $44,693,272 $55,130,100 $15,021,688 $0 $7,448,732 $0 $0 $6,497,342 $2,593,579

99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80%

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%0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20%

$1,018,132 $91,135 $0 $0 $0 $0 $0 $0 $2,370,447 $5,542,000 $11,300,948 $3,719,683 $0 $2,233,631 $0 $0 $1,999,790 $911,704

$0 $0 $0 $0 $0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$2,578,306 $680,494 $0 $0 $0 $0 $0 $0 $17,590,942 $39,151,272 $43,829,152 $11,302,005 $0 $5,215,101 $0 $0 $4,497,552 $1,681,875

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0‐$717,248 ‐$125,328 $0 $0 $0 $0 $0 $0 ‐$2,690,316 ‐$6,235,910 ‐$8,464,715 ‐$2,206,787 $0 ‐$1,204,164 $0 $0 ‐$1,050,891 ‐$495,384

$253.67 $383.16 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $461.41 $443.05 $365.39 $361.41 #DIV/0! $305.62 #DIV/0! #DIV/0! $302.01 $239.58$353.84 $434.48 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $523.59 $505.76 $459.60 $480.36 #DIV/0! $436.52 #DIV/0! #DIV/0! $436.30 $369.46$353.13 $433.61 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $522.54 $504.75 $458.68 $479.40 #DIV/0! $435.64 #DIV/0! #DIV/0! $435.42 $368.72

URRT Part II – Consumer Friendly Justification

INAC-131478481 Consumer Friendly Justification KHPE Small Group May 21, 2018

Scope and Range of the Rate Increase:

Keystone Health Plan East ("KHPE”) is revising premium rates for the Pennsylvania Small Group ACA compliant products, effective from January 1, 2019. The proposed revisions to each plan are shown on the second page of this exhibit. About 114,000 members will be affected.

Financial Experience of the Product:

KHPE is required by federal law to pay out a minimum of 80% percent of premium dollars for medical claims—this is referred to as the minimum Medical Loss Ratio (MLR). The rate action proposed in this filing is expected to achieve a Medical Loss Ratio of greater than 80%.

Changes in Medical Service Costs:

Premium rates for health care insurance are increasing as the cost of health care service rise. Health care service costs increase as health care providers increase their fees, members use more health care services and supplies, and the types of health care services and supplies change, among other factors. We are projecting that claims will increase by 6.9% in 2019. Nearly half of the change in health care service costs is driven by changes to health care provider fees.

Changes in Benefits:

Some plan benefits are mandated by federal and state law. Benefit changes for some plans were also made. All changes in benefits are in compliance with the uniform modifications rules stipulated by the Federal government.

Administrative Costs:

The premium rates presented in this filing include a 2% contribution to reserves. Furthermore, the Affordable Care Act (ACA) imposes taxes and other levies.

URRT Part II – Consumer Friendly Justification

INAC-131478481 2 Consumer Friendly Justification

KHPE Small Group May 21, 2018

HIOS ID Plan Name 1Q % Change 2Q % Change 3Q % Change 4Q % Change

33871PA0100020 Keystone HMO Platinum Preferred $10/$20/$150 0.7% 1.6% 5.7% 7.7%


33871PA0100022 Keystone HMO Gold Preferred $35/$70/$650 0.2% 1.1% 5.1% 7.2%

33871PA0100023 Keystone HMO Gold Classic $1,500/$25/$50/90% -3.0% -2.1% 1.8% 3.8%

33871PA0100024 Keystone HMO Silver Classic $4,250/$25/$50/70% -0.5% 0.4% 4.4% 6.4%

33871PA0100025 Keystone HMO Silver Classic $3,250/$30/$60/50% -0.1% 0.8% 4.8% 6.9%

33871PA0100026 Keystone HMO Bronze Essential $6,850/$50/$100/$700 1.0% 1.9% 6.9% 8.1%

33871PA0100044 Keystone HMO Gold Proactive 1.6% 2.5% 6.6% 8.7%

33871PA0100045 Keystone HMO Silver Proactive 1.3% 2.2% 6.4% 8.4%

33871PA0100047 Keystone HMO Gold Classic $2,500/$40/$80/100% -0.4% 0.5% 4.5% 6.5%

33871PA0100048 Keystone HMO Silver Classic $4,500/$40/$80/100% 0.6% 1.5% 5.5% 7.6%

33871PA0100049 Keystone HMO Silver Secure $5,000/$40/$80/$600 -0.5% 0.4% 4.4% 6.4%


33871PA0110011 Keystone DPOS Platinum Preferred $10/$20/$150 0.6% 1.5% 5.6% 7.6%

33871PA0110012 Keystone DPOS Platinum Preferred $20/$40/$200 0.6% 1.5% 5.6% 7.6%

33871PA0110013 Keystone DPOS Gold Preferred $35/$70/$650 0.1% 0.9% 5.0% 7.0%

33871PA0110014 Keystone DPOS Gold Classic $1,500/$25/$50/90% -3.0% -2.1% 1.8% 3.8%

33871PA0110016 Keystone DPOS Silver Classic $4,250/$25/$50/70% -0.4% 0.5% 4.6% 6.6%

33871PA0110019 Keystone DPOS Silver Classic $3,250/$30/$60/50 -0.1% 0.8% 4.8% 6.9%

33871PA0110020

Keystone DPOS Bronze Essential $6,850/$50/$100/$700 0.9% 1.8% 5.9% 7.9%

INAC-131478481 1 URRT Part III KHPE Small Group May 21, 2018

GENERAL OVERVIEW

PURPOSES

This Actuarial Memorandum is provided along with the Unified Rate Review Template (URRT) to provide

certain information to support the gross premium for the single risk pool for small group market health

care insurance underwritten by Keystone Health Plan East in the Commonwealth of Pennsylvania. It is

provided as a component of an application for certification as a Qualified Health Plan and a state rate

filing. This submission may not be appropriate for other purposes.

GENERAL INFORMATION

COMPANY IDENTIFYING INFORMATION

Company Legal Name: Keystone Health Plan East (“KHPE”)

State: Pennsylvania

HIOS Issuer ID (5-digit): 33871

Market: Small Group

Effective Date(s): 1/1/2019-3/31/2019, 4/1/2019 – 6/30/2019, 7/1/2019 – 9/30/2019,

10/1/2019 – 12/31/2019

Worksheet 1 of the accompanying URRT contains experience period data and development of the

projected Single Risk Pool Gross Premium Average Rate PMPM for the small group market for KHPE.

Worksheet 2 contains experience period data and projections by product for the single risk pool for the

same entities.

COMPANY CONTACT INFORMATION

Primary Contact Name: XXXXXXXXXXXX

Primary Contact Telephone Number: XXXXXXXXXXXX

Primary Contact Email Address: XXXXXXXXXXXXXXXXXXXXXXXX

PROPOSED RATE INCREASE

The changes to the single risk pool gross premium average rate per member per month (PMPM) from

calendar year 2017 to calendar year 2019 were incorporated into the pricing and reflected in the Unified

Rate Review Template. The changes are driven by factors including: changes in market-wide population

risk morbidity and covered services, increasing unit costs for medical services, increasing utilization of

medical services, increasing fees and taxes imposed by the federal government, anticipated costs to

administer the plan, anticipated revenue or payments due to market-wide risk adjustment, and the

discontinuance of net reinsurance payments from the Federal Transitional Reinsurance Program.


The weighted average increase across KHPE plans based on projected membership, inclusive of the

impact of benefit and cost sharing changes, is 4.3%. The minimum increase is 0.6% and the maximum

increase is 5.3%.

WORKSHEET 1: DATA COLLECTION TEMPLATE

SECTION I: EXPERIENCE PERIOD PREMIUM AND CLAIMS

PAID THROUGH DATE

Experience period premium, claims, and member months are obtained from the company’s internal

data warehouse. The claims data is collected for incurred dates from January through December 2017

and paid through February 2018. Earned premiums and member months are for January through

December 2017. The data are for all direct-written small group business of KHPE in the Commonwealth

of Pennsylvania, including out-of-network claims written by KHPE but paid by QCC for POS plans.

PREMIUMS (NET OF MLR REBATE) IN EXPERIENCE PERIOD

Earned Premiums (net of MLR Rebate) in Experience Period are developed by summing the earned

premium reported in the company’s internal data warehouse and adjusting for MLR rebates, if any, for

the period. Although 2017 federal MLR rebate calculations are not final as of the writing of this

memorandum, no federal MLR rebates are expected for calendar year 2017, so no adjustment to earned

premium for MLR rebates is needed.

The calculation for federal minimum loss ratio rebates is based on 2015, 2016, and 2017 experience of

earned premium, incurred claims, quality improvement expenses, and taxes. The three years of

experience is blended for all segments.

ALLOWED AND INCURRED CLAIMS INCURRED DURING THE EXPERIENCE PERIOD

Paid-to-Date and Incurred Claims, and Member Months

Insurer fee-for-service claims expenses and member liabilities for dates of service in January 2017

through December 2017 and paid through February 2018 are sourced from the IBCFOC’s internal data

warehouse. The claims and member liabilities are completed with incurred but not reported (IBNR)

adjustments to develop ultimate incurred insurer fee-for-service claims expenses and member liabilities

for the January through December 2017 period. Capitation amounts are also sourced from the internal

data warehouse for the January through December 2017 period but they are not adjusted for IBNR.

Allowed Claims

Allowed claims are determined by separately obtaining paid-to-date fee-for-service claims and member

cost-sharing amounts, applying claim lag factors to those amounts to estimate ultimate incurred fee-for-

service claims and member-sharing amounts and adding them together with capitation amounts.


Allowed claims do not include ineligible claims, payments for services other than medical care provided,

recovery payments related to internal large claim pooling mechanisms, or active live reserves.

IBNR Development

Medical fee for service incurred but not reported (IBNR) claims are modeled through the use of standard

claim lag methodologies. A range of results is developed, and a provision for adverse deviation is

applied. The provision for adverse deviation is dependent on many factors such as stability, size, product

mix, etc.

The completion factors are developed annually in the 2Q – 3Q period. We do not believe our IBNR is

unusually high or unusually low for incurred 2017 paid through February 2018.

Experience Period Index Rate

The Index Rate of Experience Period is estimated by removing cost and utilization trend from the Index

Rate for Projection Period.

SECTION II: ALLOWED CLAIMS, PMPM BASIS

BENEFIT CATEGORIES

Utilization and Unit Cost data for allowed claims in the experience period are provided in Section II. The

data is provided by benefit category using a standardized indicator from the internal data warehouse

that assigns each claim line to a category based on the type of provider and the location of the service.

The utilization and unit cost data are provided for the following categories: Inpatient Hospital admits,

Outpatient Hospital visits, Professional visits, Other Medical visits, Capitation per member per month

(PMPM), and Prescription Drug scripts.

Experience Period capitation is reported as a per member per month (PMPM) value. In order to

complete the URRT, the Utilization per 1,000 statistics for capitated services only is reported as 1,000 so

that the appropriate capitation PMPM is reported.

PROJECTION FACTORS

The estimated incurred claims experience on an allowed basis for January 2017 through December 2017

is projected to the future rating period by several factors. Factors were calculated from the combined

experience of QCC and KHPE.

Changes in Population Risk Morbidity

Experience period allowed claims are adjusted to account for differences in the average morbidity of the

single risk pool population underlying the experience and the anticipated population in the projection

period. This adjustment reflects changes in the small group market-wide morbidity.


Changes in Other Factors

Experience period allowed claims are adjusted to account for differences in the single risk pool

population underlying the experience and the anticipated population in the projection period pertaining

to several factors not due to changes in morbidity or the costs and utilization of medical care. This

adjustment reflects: additional benefits required to be covered as essential health benefits; recently

mandated benefits required by state law that are not reflected in the experience period data; benefits in

the experience that are removed for the projection period; anticipated changes in the average

utilization of services due to differences in average cost sharing requirements during the experience

period and average cost sharing requirements in the projection period; changes in demographic

characteristics of the single risk pool experience period population and the projection period population

(including age, gender, region, and tobacco use); changes in the provider network (adding or removing a

provider system or introducing a limited network option); and anticipated changes in pharmacy rebates.

Trend Factors

a. Annualized Cost Trend

Annual cost trend reflects changes in costs of medical treatment due to medical inflation and changes in

the distribution of services across network providers. The trend value is developed by reviewing

historical medical costs for the single risk pool and adjusting them for anticipated future provider

contracting reimbursement levels. The data is normalized for changes in age, benefit changes during the

experience period, changes to provider contracts, and prescription drug formulary, and new drugs

brought to market.

b. Annualized Utilization Trend

Annual utilization trend reflects the change in the number of units per 1,000 members for a fixed level

of illness burden and includes changes due to the mix and intensity of services provided and changes

related to shifts in product mix. It also includes effects of selection, if any, since this cannot be reflected

in the relative cost of the various products and plans offered.

CREDIBILITY MANUAL RATE DEVELOPMENT

The experience period claims for the single risk pool are determined to be fully credible; therefore no

credibility adjustment is required.

SECTION III: PROJECTED EXPERIENCE

PAID TO ALLOWED RATIO

The Projected Allowed Experience Claims PMPM shown in Worksheet 1 represents projected allowed

claims experience PMPM for the projected portfolio of plans. The Paid to Allowed Average Factor in


Projection Period adjusts the allowed down to Projected Incurred Claims before ACA reinsurance and

risk adjustment for the population anticipated to be covered in the projection period. The Projected

Incurred Claims before ACA reinsurance and risk adjustment represents the net amount of incurred

insurer claim liability expected in the projection period, net of member cost sharing and cost sharing

paid by HHS on behalf of low-income members. It reflects the average benefit level anticipated during

the projection period. The ratio was calculated using incurred (before ACA reinsurance and risk

adjustment) and allowed PMPMs from worksheet two of the URRT.

RISK ADJUSTMENT AND REINSURANCE

Projected Risk Adjustment PMPM

Projected Risk Adjustment is accounted for in Projected Incurred Claims before ACA Reinsurance and

Risk Adjustment to reflect anticipated risk adjustment transfer amounts for the projection period. The

amount reflects the projected morbidity for the single risk pool for IBCFOC in the projection period.

The estimated risk adjustment revenue for all of the plans in the risk pool is developed using the

following methodology. We recognize that the HHS payment transfer formula implies that the projected

incurred claims based solely on the experience period single risk pool claims need to be adjusted by the

ratio of the current statewide market’s risk relative to allowable rating factor (ARF) for age compared to

the single risk pool’s risk relative to ARF presented during the experience period. This adjustment,

together with the assumed future changes in population risk morbidity, results in the issuer’s pricing

being consistent with the anticipated morbidity level of the future statewide market.

The anticipated risk adjustment transfer revenue is allocated proportionally based on plan premium.

The Projected Risk Adjustment is subtracted from Projected Incurred Claims before ACA Risk Adjustment

to reflect anticipated receipt of risk adjustment transfer amounts for the projection period.

When the projected risk adjustment amounts for KHPE and QCC are combined, the result is consistent

with the projection made in our submission. We also consider preliminary 2017 risk transfer results.

NON-BENEFIT EXPENSES AND PROFIT & RISK

Administrative Expense Load

An Administrative Expense Load is applied to Projected Incurred Claims to reflect expenses related to

quality improvement and fraud detection/recovery and other expenses of operating a business, broker

commissions, and premium payment processing fees.

Profit & Risk Load/Contribution to Surplus

A Profit & Risk Load/Contribution to Surplus for the single risk pool is applied to Projected Incurred

Claims for the projection period, if applicable.

Taxes and Fees


A Taxes & Fees load is applied to Projected Incurred Claims to pass through fees and taxes levied by the

federal and state governments.

PROJECTED LOSS RATIO

The projected loss ratio for the single risk pool is estimated to exceed 80% reflecting premium

adjustments permitted by the federal MLR calculation.

SINGLE RISK POOL

The single risk pool reflects all covered lives for every small group non-grandfathered product and plan combination for KHPE in the state of Pennsylvania. It is established according to the Single Risk Pool requirements in 45 CFR § 156.80(d).

INDEX RATE

The Index Rate is defined as the EHB portion of projected allowed claims divided by all projected single risk pool lives. The Index Rate is the same value for all non-grandfathered plans for KHPE Small Group Plans in Pennsylvania. The Index Rate reflects the twelve month projection for calendar year 2019. It has been developed following the specifications of 45 CFR § 156.80(d)(1).

MARKET ADJUSTED INDEX RATE

The Market Adjusted Index rate is calculated as the Index Rate adjusted for all allowable market-wide

modifiers defined in the market rating rules: federal reinsurance program adjustment, risk adjustment

and exchange user fees. The Market Adjusted Index Rate reflects the average demographic

characteristics of the single risk pool.

PLAN ADJUSTED INDEX RATE

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

allowable plan level modifiers defined in the market rating rule. These include actuarial value and cost

sharing adjustment, provider network, delivery system and utilization management adjustment,

adjustment for benefits in addition to the EHBs, impact of specific eligibility categories for the

catastrophic plan and administrative costs.

CALIBRATION

The plan adjusted index rate is projected for all products using the same anticipated age distribution

and the mandated age curve. Therefore the consumer adjusted premium rate is the plan adjusted index

rate divided by the average age, geographic and tobacco factors for the expected distribution. The

average age of the combined small group risk pool population is 36.


The Average Age factor is the weighted average age factor based on the projected membership. The

Tobacco Factor is calculated as the projected average factor for tobacco users multiplied by the

projected tobacco use prevalence.

There is only one geographic rating area for this filing. The geographic rating area factor for this filing is

1.0.

WORKSHEET 2: PRODUCT-PLAN DATA COLLECTION

AV METAL VALUES

The AV Metal Values included in Worksheet 2 of the URRT were valued using the AV Calculator, where

possible, otherwise the AV Metal Values were developed under an alternate methodology. Actuarial

certifications required by 45 CFR Part 156, §156.135 are provided in a separate document.

AV PRICING VALUES

The AV Pricing Value represents the cumulative effect of adjustments made by plan to move from the

Market Adjusted Index Rate to the Plan Adjusted Index Rate.

MEMBERSHIP PROJECTIONS

Enrollment is projected based on current and anticipated enrollment by plan. Items impacting these

projections include changes in the size of the market due to introduction of guarantee issue

requirements, the individual mandate, and the introduction of a Basic Health Program.

TERMINATED PLANS

No plans are being terminated during 2019.

WARNING ALERTS

There are no warning alerts in URRT part 1.


ACTUARIAL CERTIFICATION

I, XXXXXXXXXXXX, am Director & Actuary of Commercial Markets for the Independence Blue Cross Family of Companies. I am a member of the Society of Actuaries and the American Academy of Actuaries with the education and experience necessary to perform the work necessary and meet the Qualification Standards of the American Academy of Actuaries to render the qualified actuarial opinion contained herein. The developed rates and memorandum have been prepared in conformity with appropriate Actuarial Standards of Practice and the Academy’s Code of Professional Conduct.

The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the premium rates and allowable rating factors. Rather, it represents information required by Federal regulation to be provided in support of the review of gross premium rate increases, for certification of qualified health plans for Federally facilitated exchanges, and for certification that the index rate is developed in accordance with Federal regulation and used consistently and only adjusted by the allowable modifiers.

I hereby certify that, to the best of my knowledge and judgment, the following:

▪ The projected index rate is:

—In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.08(d)(1) and 147.102);

—Developed in compliance with applicable Actuarial Standards of Practice;

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

—Neither excessive nor deficient.

▪ The index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2) were used to generate plan level rates.

▪ The percent of total premium that represents essential health benefits included in Worksheet 2, Sections III and IV were calculated in accordance with actuarial standards of practice.

▪ Geographic rating factors reflect only differences in the costs of delivery of and do not include differences for population morbidity by geographic area.

▪ The 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, unless an alternate methodology was required. If an alternate methodology was used to calculate the AV Metal Value for at least one plan offered, a copy of the actuarial certification required by 45 CFR Part 156, §156.135 will be included.

XXXXXXXXXXXX XXXXXXXXXXXX May 21, 2018