v > ] ( / v µ v } u v Ç E Á z } l / v ] À ] µ o } v À ... · NY Small Group Portfolio | Summary of Benefits Contents NY Platinum OFF ONLY 2 NY Gold OFF ONLY 3 NY Silver OFF

A-1

Proprietary

Aetna Life Insurance Company

New York Individual Conversion

Rate Manual

Table of Contents

Description Page

Table of Contents A-1

General A-2

Premium Rate Manual A-3

Product Summary B-1

Plan Forms and Actuarial Value Benefits C-1

Rate Tables D-1

List of Applicable Forms E-1

Commissions Schedule and Incentive Fees F-1

Projected Loss Ratio G-1

A-2

Proprietary


New York Individual

General

This rate manual contains worksheets and instructions for calculating the community rates for the New York Individual Conversion Plans available from Aetna Life Insurance Company. It is in accordance with Insurance Law Section 3231 (d) Rate Applications and includes rates for Aetna’s products that will be offered effective January 1, 2020.

A-3

Proprietary


New York Individual Premium Rate Manual

1. 2020 Base Rate

Silver Base Premium Rate $941.14

2. Dependent up to Age 30 Rider The Federal Health Care Reform allows for coverage for dependents on their parent’s health plan until age 26. The New York "Age 29" Dependent Coverage Extension permits young adults to continue or obtain coverage under a parent’s policy through the age of 29. For subscribers who choose to have the Dependent Up to Age 30 rider, the Silver Base Premium Rate is 3% higher than the rate shown in Step 1 above. The Silver Base Premium Rate with Dependent Up to Age 30 rider is:

Silver Base Premium Rate $969.38

3. Plan Pricing Values The plan factors shown on page C-1 reflect the pricing differential for each product.

4. Standardized Rating Region The table below shows the New York Individual rating area factors that reflect differences in cost by geographic area. The rating regions listed below are based on the required ACA standardized rating regions.

Rating Region Counties Area Factor

Region 1 Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington

0.82

Region 2 Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming

0.90

Region 3 Delaware, Dutchess, Orange, Putnam, Sullivan, Ulster 1.03 Region 4 Bronx, Kings, New York, Queens, Richmond, Rockland,

Westchester 1.00

Region 5 Livingston, Monroe, Ontario, Seneca, Wayne, Yates 0.70 Region 6 Broome, Cayuga, Chemung, Cortland, Onondaga, Schuyler,

Steuben, Tioga, Tompkins 0.79

Region 7 Chenango, Clinton, Essex, Franklin, Hamilton, Herkimer, Jefferson, Lewis, Madison, Oneida, Oswego, Otsego, St. Lawrence

0.82

Region 8 Nassau, Suffolk 1.00

A-4

Proprietary

One Child Two Children Three or More Children0.412 One Child Rate * 2 One Child Rate * 3

Tier RelativitiesSingle 1

Singe + Spouse 2Single + Child(ren) 1.7

Single + Spouse + Child(ren) 2.85

5. Standardized Census Tiers

All of Aetna’s New York Individual products will be priced to reflect the following tiers and relativities specified by the DFS.

6. Child Only Plans Aetna will offer one Child Only product in each metal tier. The Child Only rate is set at 41.2% of the corresponding single rate product. For a Child Only plan that covers two children in a family, the premium rate would be twice the one child premium rate. For a Child Only plan that covers three or more children in a family, the premium rate would be three times the one child premium rate, consistent with HHS Regulations.

7. Subscriber Rate

For subscribers without the Dependent Up to Age 30 rider, the subscriber rate is equal to Step 1 x Step 3 x Step 4 x Step 5 or Step 6, rounded to the nearest cent. For subscribers who choose the Dependent Up to Age 30 rider, the subscriber rate is equal to Step 2 x Step 3 x Step 4 x [Step 5 or Step 6], rounded to the nearest cent. The rate tables are shown in Section D. The applicability period for the rate tables is January 1, 2020 through December 31, 2020.

A-5

Proprietary

8. Example of Rate Calculations

Region 2 with Aetna Silver $20 Copay OAEPO (Base Silver) PlanBase Rate

Age 30 Rider

Plan Pricing Values

Rating Region

Census Tiers

Child Only Plans

Subscriber Rate

Single $941.14 1 0.9 1 $847.03Single + Spouse $941.14 1 0.9 2 $1,694.06Single + Child(ren) $941.14 1 0.9 1.7 $1,439.95Single + Spouse + Child(ren) $941.14 1 0.9 2.85 $2,414.03Single + Child(ren) with Dependent Up to Age 30 Rider $941.14 1.03 1 0.9 1.7 $1,483.15Single + Spouse + Child(ren) with Dependent Up to Age 30 Rider $941.14 1.03 1 0.9 2.85 $2,486.46One Child $941.14 1 0.9 0.412 $348.98Two Children $941.14 1 0.9 0.824 $697.95Three or More Children $941.14 1 0.9 1.236 $1,046.93

Region 8 with Aetna Platinum $5 Copay OAEPO PlanBase Rate Age 30

RiderPlan Pricing

ValuesRating Region

Census Tiers

Child Only Plans

Subscriber Rate

Single $941.14 1.57775456 1 1 $1,484.89Single + Spouse $941.14 1.57775456 1 2 $2,969.79Single + Child(ren) $941.14 1.57775456 1 1.7 $2,524.32Single + Spouse + Child(ren) $941.14 1.57775456 1 2.85 $4,231.95Single + Child(ren) with Dependent Up to Age 30 Rider $941.14 1.03 1.57775456 1 1.7 $2,600.05Single + Spouse + Child(ren) with Dependent Up to Age 30 Rider $941.14 1.03 1.57775456 1 2.85 $4,358.91One Child $941.14 1.57775456 1 0.412 $611.78Two Children $941.14 1.57775456 1 0.824 $1,223.55Three or More Children $941.14 1.57775456 1 1.236 $1,835.33


17210

Exhibit A-2

NY Small Group Portfolio | Summary of Benefits

Contents

NY Platinum OFF ONLY 2

NY Gold OFF ONLY 3

NY Silver OFF ONLY 4

NY Bronze OFF ONLY 5

#Proprietary


17210

Exhibit A-2

Page 2 of 5

New YorkNY Platinum OFF ONLY

Summary of Features

Deductible

Individual

Family

Coinsurance

(Member Responsibility)

Out-of-Pocket Maximum

Individual

Familiy

Primary Care Visit to Treat an Injury or Illness

(excludes Preventative and X-rays)

Specialist Visit

All Inpatient Hospital Services

(includes Mental/Behavioral Health and Substance Abuse)

Emergency Room Services

Mental/Behavioral Health and Substance Abuse Disorder

Outpatient Services

Imaging (CT/PET Scans, MRIs)

Rehabilitative Speech Therapy

Rehabilitative Occupational and Rehabilitative Physical

Therapy

Preventive Care/Screening/Immunization

Laboratory Outpatient and Professional Services

X-rays and Diagnostic Imaging

Skilled Nursing Facility

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

Outpatient Surgery Physician/Surgical Services

Pharmacy

Pharmacy Deductible

Individual

Generic incl. Specialty (Pref&Non-Pref)

Brand incl. Specialty (Pref)

Brand incl. Specialty (Non-Pref)

$2,000

In Network

$500

$1,000

10%

$0 once out-of-pocket max. is satisfied

10% after deductible

$4,000

All cost sharing accumulates to the Out of Pocket Maximum above

$5 per visit

$30 per visit


$250 per visit after deductible

$5 per visit




0%

$10 (Deductible Waived)

$30

$60





In-Network

Integrated with Medical


17210

Exhibit A-2

Page 3 of 5

New YorkNY Gold OFF ONLY

Summary of Features

Deductible

Individual

Family

Coinsurance



Individual

Familiy



Specialist Visit





Outpatient Services




Therapy







Pharmacy

Pharmacy Deductible

Individual




$5,200

In Network

$1,400

$2,800

20%



$10,400


$10 per visit

$40 per visit



$10 per visit




0%


$35

$70





In-Network



17210

Exhibit A-2

Page 4 of 5

New YorkNY Silver OFF ONLY

Summary of Features

Deductible

Individual

Family

Coinsurance



Individual

Familiy



Specialist Visit





Outpatient Services




Therapy







Pharmacy

Pharmacy Deductible

Individual




$7,200

In Network

$3,900

$7,800

30%



$14,400


$20 per visit

$75 per visit



$20 per visit




0%


$40

$100





In-Network



17210

Exhibit A-2

Page 5 of 5

New YorkNY Bronze OFF ONLY

Summary of Features

Deductible

Individual

Family

Coinsurance



Individual

Familiy



Specialist Visit





Outpatient Services




Therapy







Pharmacy

Pharmacy Deductible

Individual




$7,650

In Network

$5,000

$10,000

50%



$15,300










0%


$40

$100





In-Network


Product HIOS Plan ID PlanExchange ON/OFF Metallic Tier

Actuarial Value

Plan Factors

EPO 17210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum 90.40% 1.5778EPO 17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum 90.40% 1.5778EPO 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum 90.40% 1.5778EPO 17210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold 81.93% 1.2821EPO 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold 81.93% 1.2821EPO 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold 81.93% 1.2821EPO 17210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver 71.98% 1.0000EPO 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver 71.98% 1.0000EPO 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver 71.98% 1.0000EPO 17210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze 61.94% 0.6938EPO 17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze 61.94% 0.6938EPO 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze 61.94% 0.6938



C-1#Proprietary



Monthly PremiumJanuary 1, 2020 through December 31, 2020

HIOS Plan-Id PlanExchange ON/OFF

Metallic Tier Rating Area Tier Monthly Premium

17210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 01 Single 1217.6117210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 01 Single + Child(ren) 2069.9417210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 01 Single + Spouse 2435.2317210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 01 Single + Spouse + Child(ren) 3470.2017210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 02 Single 1336.4017210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 02 Single + Child(ren) 2271.8917210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 02 Single + Spouse 2672.8117210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 02 Single + Spouse + Child(ren) 3808.7517210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 03 Single 1529.4417210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 03 Single + Child(ren) 2600.0517210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 03 Single + Spouse 3058.8817210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 03 Single + Spouse + Child(ren) 4358.9117210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 04 Single 1484.8917210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 04 Single + Child(ren) 2524.3217210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 04 Single + Spouse 2969.7917210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 04 Single + Spouse + Child(ren) 4231.9517210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 05 Single 1039.4317210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 05 Single + Child(ren) 1767.0217210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 05 Single + Spouse 2078.8517210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 05 Single + Spouse + Child(ren) 2962.3617210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 06 Single 1173.0717210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 06 Single + Child(ren) 1994.2117210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 06 Single + Spouse 2346.1317210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 06 Single + Spouse + Child(ren) 3343.2417210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 07 Single 1217.6117210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 07 Single + Child(ren) 2069.9417210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 07 Single + Spouse 2435.2317210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 07 Single + Spouse + Child(ren) 3470.2017210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 08 Single 1484.8917210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 08 Single + Child(ren) 2524.3217210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 08 Single + Spouse 2969.7917210NY0120021 Aetna Platinum $5 Copay OAEPO OFF Platinum Region 08 Single + Spouse + Child(ren) 4231.95

D-1#Proprietary






17210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 01 Single 989.4717210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 01 Single + Child(ren) 1682.1017210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 01 Single + Spouse 1978.9417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 01 Single + Spouse + Child(ren) 2819.9917210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 02 Single 1086.0017210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 02 Single + Child(ren) 1846.2117210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 02 Single + Spouse 2172.0117210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 02 Single + Spouse + Child(ren) 3095.1117210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 03 Single 1242.8717210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 03 Single + Child(ren) 2112.8817210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 03 Single + Spouse 2485.7417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 03 Single + Spouse + Child(ren) 3542.1817210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 04 Single 1206.6717210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 04 Single + Child(ren) 2051.3417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 04 Single + Spouse 2413.3417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 04 Single + Spouse + Child(ren) 3439.0117210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 05 Single 844.6717210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 05 Single + Child(ren) 1435.9417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 05 Single + Spouse 1689.3417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 05 Single + Spouse + Child(ren) 2407.3117210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 06 Single 953.2717210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 06 Single + Child(ren) 1620.5617210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 06 Single + Spouse 1906.5417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 06 Single + Spouse + Child(ren) 2716.8217210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 07 Single 989.4717210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 07 Single + Child(ren) 1682.1017210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 07 Single + Spouse 1978.9417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 07 Single + Spouse + Child(ren) 2819.9917210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 08 Single 1206.6717210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 08 Single + Child(ren) 2051.3417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 08 Single + Spouse 2413.3417210NY0120018 Aetna Gold $10 Copay OAEPO OFF Gold Region 08 Single + Spouse + Child(ren) 3439.01

D-2#Proprietary






17210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 01 Single 771.7417210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 01 Single + Child(ren) 1311.9517210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 01 Single + Spouse 1543.4817210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 01 Single + Spouse + Child(ren) 2199.4517210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 02 Single 847.0317210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 02 Single + Child(ren) 1439.9517210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 02 Single + Spouse 1694.0617210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 02 Single + Spouse + Child(ren) 2414.0317210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 03 Single 969.3817210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 03 Single + Child(ren) 1647.9417210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 03 Single + Spouse 1938.7617210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 03 Single + Spouse + Child(ren) 2762.7317210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 04 Single 941.1417210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 04 Single + Child(ren) 1599.9417210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 04 Single + Spouse 1882.2917210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 04 Single + Spouse + Child(ren) 2682.2617210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 05 Single 658.8017210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 05 Single + Child(ren) 1119.9617210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 05 Single + Spouse 1317.6017210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 05 Single + Spouse + Child(ren) 1877.5817210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 06 Single 743.5017210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 06 Single + Child(ren) 1263.9617210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 06 Single + Spouse 1487.0117210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 06 Single + Spouse + Child(ren) 2118.9917210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 07 Single 771.7417210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 07 Single + Child(ren) 1311.9517210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 07 Single + Spouse 1543.4817210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 07 Single + Spouse + Child(ren) 2199.4517210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 08 Single 941.1417210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 08 Single + Child(ren) 1599.9417210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 08 Single + Spouse 1882.2917210NY0120024 Aetna Silver $20 Copay OAEPO OFF Silver Region 08 Single + Spouse + Child(ren) 2682.26

D-3#Proprietary






17210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 01 Single 535.4617210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 01 Single + Child(ren) 910.2817210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 01 Single + Spouse 1070.9217210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 01 Single + Spouse + Child(ren) 1526.0617210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 02 Single 587.7017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 02 Single + Child(ren) 999.0917210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 02 Single + Spouse 1175.4017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 02 Single + Spouse + Child(ren) 1674.9517210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 03 Single 672.5917210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 03 Single + Child(ren) 1143.4017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 03 Single + Spouse 1345.1817210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 03 Single + Spouse + Child(ren) 1916.8817210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 04 Single 653.0017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 04 Single + Child(ren) 1110.1017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 04 Single + Spouse 1306.0017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 04 Single + Spouse + Child(ren) 1861.0517210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 05 Single 457.1017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 05 Single + Child(ren) 777.0717210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 05 Single + Spouse 914.2017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 05 Single + Spouse + Child(ren) 1302.7417210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 06 Single 515.8717210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 06 Single + Child(ren) 876.9817210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 06 Single + Spouse 1031.7417210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 06 Single + Spouse + Child(ren) 1470.2317210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 07 Single 535.4617210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 07 Single + Child(ren) 910.2817210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 07 Single + Spouse 1070.9217210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 07 Single + Spouse + Child(ren) 1526.0617210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 08 Single 653.0017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 08 Single + Child(ren) 1110.1017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 08 Single + Spouse 1306.0017210NY0120015 Aetna Bronze Deductible Only OAEPO OFF Bronze Region 08 Single + Spouse + Child(ren) 1861.05

D-4#Proprietary



Monthly Premium (Child Only)January 1, 2020 through December 31, 2020


Metallic TierRating Area

One Child Monthly Premium

Two Children Monthly Premium

Three or More Children Monthly Premium

17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum Region 01 501.66$ 1,003.31$ 1,504.97$ 17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum Region 02 550.60$ 1,101.20$ 1,651.80$ 17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum Region 03 630.13$ 1,260.26$ 1,890.39$ 17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum Region 04 611.78$ 1,223.55$ 1,835.33$ 17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum Region 05 428.24$ 856.49$ 1,284.73$ 17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum Region 06 483.30$ 966.61$ 1,449.91$ 17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum Region 07 501.66$ 1,003.31$ 1,504.97$ 17210NY0120019 Aetna Platinum $5 Copay OAEPO C/O OFF Platinum Region 08 611.78$ 1,223.55$ 1,835.33$ 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold Region 01 407.66$ 815.32$ 1,222.98$ 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold Region 02 447.43$ 894.87$ 1,342.30$ 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold Region 03 512.06$ 1,024.12$ 1,536.19$ 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold Region 04 497.15$ 994.30$ 1,491.44$ 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold Region 05 348.00$ 696.01$ 1,044.01$ 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold Region 06 392.75$ 785.49$ 1,178.24$ 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold Region 07 407.66$ 815.32$ 1,222.98$ 17210NY0120016 Aetna Gold $10 Copay OAEPO C/O OFF Gold Region 08 497.15$ 994.30$ 1,491.44$ 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver Region 01 317.96$ 635.91$ 953.87$ 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver Region 02 348.98$ 697.95$ 1,046.93$ 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver Region 03 399.38$ 798.77$ 1,198.15$ 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver Region 04 387.75$ 775.50$ 1,163.25$ 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver Region 05 271.43$ 542.85$ 814.28$ 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver Region 06 306.32$ 612.65$ 918.97$ 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver Region 07 317.96$ 635.91$ 953.87$ 17210NY0120022 Aetna Silver $20 Copay OAEPO C/O OFF Silver Region 08 387.75$ 775.50$ 1,163.25$ 17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze Region 01 220.61$ 441.22$ 661.83$ 17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze Region 02 242.13$ 484.27$ 726.40$ 17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze Region 03 277.11$ 554.21$ 831.32$ 17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze Region 04 269.04$ 538.07$ 807.11$ 17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze Region 05 188.33$ 376.65$ 564.98$ 17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze Region 06 212.54$ 425.08$ 637.62$ 17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze Region 07 220.61$ 441.22$ 661.83$

D-5#Proprietary



Monthly Premium (Child Only)January 1, 2020 through December 31, 2020


Metallic TierRating Area

One Child Monthly Premium

Two Children Monthly Premium

Three or More Children Monthly Premium

17210NY0120013 Aetna Bronze Deductible Only OAEPO C/O OFF Bronze Region 08 269.04$ 538.07$ 807.11$

D-6#Proprietary



Monthly Premium (with Dependent Coverage Up to Age 30 Rider)January 1, 2020 through December 31, 2020


Metallic Tier Rating Area TierMonthly Premium

17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 01 Single 1,254.14$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 01 Single + Child(ren) 2,132.04$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 01 Single + Spouse 2,508.28$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 01 Single + Spouse + Child(ren) 3,574.30$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 02 Single 1,376.50$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 02 Single + Child(ren) 2,340.04$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 02 Single + Spouse 2,752.99$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 02 Single + Spouse + Child(ren) 3,923.02$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 03 Single 1,575.32$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 03 Single + Child(ren) 2,678.05$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 03 Single + Spouse 3,150.65$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 03 Single + Spouse + Child(ren) 4,489.67$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 04 Single 1,529.44$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 04 Single + Child(ren) 2,600.05$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 04 Single + Spouse 3,058.88$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 04 Single + Spouse + Child(ren) 4,358.91$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 05 Single 1,070.61$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 05 Single + Child(ren) 1,820.03$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 05 Single + Spouse 2,141.22$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 05 Single + Spouse + Child(ren) 3,051.23$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 06 Single 1,208.26$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 06 Single + Child(ren) 2,054.04$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 06 Single + Spouse 2,416.52$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 06 Single + Spouse + Child(ren) 3,443.54$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 07 Single 1,254.14$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 07 Single + Child(ren) 2,132.04$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 07 Single + Spouse 2,508.28$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 07 Single + Spouse + Child(ren) 3,574.30$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 08 Single 1,529.44$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 08 Single + Child(ren) 2,600.05$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 08 Single + Spouse 3,058.88$ 17210NY0120020 Aetna Platinum $5 Copay OAEPO DEP 30 OFF Platinum Region 08 Single + Spouse + Child(ren) 4,358.91$

D-7#Proprietary






17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 01 Single 1,019.15$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 01 Single + Child(ren) 1,732.56$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 01 Single + Spouse 2,038.31$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 01 Single + Spouse + Child(ren) 2,904.59$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 02 Single 1,118.58$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 02 Single + Child(ren) 1,901.59$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 02 Single + Spouse 2,237.17$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 02 Single + Spouse + Child(ren) 3,187.96$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 03 Single 1,280.16$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 03 Single + Child(ren) 2,176.27$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 03 Single + Spouse 2,560.31$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 03 Single + Spouse + Child(ren) 3,648.45$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 04 Single 1,242.87$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 04 Single + Child(ren) 2,112.88$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 04 Single + Spouse 2,485.74$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 04 Single + Spouse + Child(ren) 3,542.18$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 05 Single 870.01$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 05 Single + Child(ren) 1,479.02$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 05 Single + Spouse 1,740.02$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 05 Single + Spouse + Child(ren) 2,479.53$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 06 Single 981.87$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 06 Single + Child(ren) 1,669.17$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 06 Single + Spouse 1,963.73$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 06 Single + Spouse + Child(ren) 2,798.32$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 07 Single 1,019.15$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 07 Single + Child(ren) 1,732.56$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 07 Single + Spouse 2,038.31$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 07 Single + Spouse + Child(ren) 2,904.59$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 08 Single 1,242.87$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 08 Single + Child(ren) 2,112.88$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 08 Single + Spouse 2,485.74$ 17210NY0120017 Aetna Gold $10 Copay OAEPO DEP 30 OFF Gold Region 08 Single + Spouse + Child(ren) 3,542.18$

D-8#Proprietary






17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 01 Single 794.89$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 01 Single + Child(ren) 1,351.31$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 01 Single + Spouse 1,589.78$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 01 Single + Spouse + Child(ren) 2,265.44$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 02 Single 872.44$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 02 Single + Child(ren) 1,483.15$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 02 Single + Spouse 1,744.88$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 02 Single + Spouse + Child(ren) 2,486.46$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 03 Single 998.46$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 03 Single + Child(ren) 1,697.38$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 03 Single + Spouse 1,996.92$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 03 Single + Spouse + Child(ren) 2,845.61$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 04 Single 969.38$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 04 Single + Child(ren) 1,647.94$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 04 Single + Spouse 1,938.76$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 04 Single + Spouse + Child(ren) 2,762.73$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 05 Single 678.56$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 05 Single + Child(ren) 1,153.56$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 05 Single + Spouse 1,357.13$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 05 Single + Spouse + Child(ren) 1,933.91$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 06 Single 765.81$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 06 Single + Child(ren) 1,301.87$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 06 Single + Spouse 1,531.62$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 06 Single + Spouse + Child(ren) 2,182.56$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 07 Single 794.89$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 07 Single + Child(ren) 1,351.31$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 07 Single + Spouse 1,589.78$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 07 Single + Spouse + Child(ren) 2,265.44$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 08 Single 969.38$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 08 Single + Child(ren) 1,647.94$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 08 Single + Spouse 1,938.76$ 17210NY0120023 Aetna Silver $20 Copay OAEPO DEP 30 OFF Silver Region 08 Single + Spouse + Child(ren) 2,762.73$

D-9#Proprietary






17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 01 Single 551.52$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 01 Single + Child(ren) 937.59$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 01 Single + Spouse 1,103.05$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 01 Single + Spouse + Child(ren) 1,571.84$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 02 Single 605.33$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 02 Single + Child(ren) 1,029.06$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 02 Single + Spouse 1,210.66$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 02 Single + Spouse + Child(ren) 1,725.19$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 03 Single 692.77$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 03 Single + Child(ren) 1,177.71$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 03 Single + Spouse 1,385.54$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 03 Single + Spouse + Child(ren) 1,974.39$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 04 Single 672.59$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 04 Single + Child(ren) 1,143.40$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 04 Single + Spouse 1,345.18$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 04 Single + Spouse + Child(ren) 1,916.88$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 05 Single 470.81$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 05 Single + Child(ren) 800.38$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 05 Single + Spouse 941.63$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 05 Single + Spouse + Child(ren) 1,341.82$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 06 Single 531.35$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 06 Single + Child(ren) 903.29$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 06 Single + Spouse 1,062.69$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 06 Single + Spouse + Child(ren) 1,514.34$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 07 Single 551.52$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 07 Single + Child(ren) 937.59$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 07 Single + Spouse 1,103.05$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 07 Single + Spouse + Child(ren) 1,571.84$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 08 Single 672.59$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 08 Single + Child(ren) 1,143.40$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 08 Single + Spouse 1,345.18$ 17210NY0120014 Aetna Bronze Deductible Only OAEPO DEP30 OFF Bronze Region 08 Single + Spouse + Child(ren) 1,916.88$

D-10#Proprietary

Aetna Life Insurance Company New York Conversion

E-1

Proprietary

List of Individual Conversion Off-Exchange Forms (2020)

RIDER:

OFFHIXIVLGR-96817 Family Planning Rider-3

Conversion Policy Certificates and Schedules

OffHIXIVLConv-96807-6

OffHIXIVLConv-CO-96807-6

BronzeOffHIXIVLConv-96807-6-SB

GoldOffHIXIVLConv-96807-6-SB

PlatinumOffHIXIVLConv-96807-6-SB

SilverOffHIXIVLConv-96807-6-SB

F-1

Proprietary


New York Individual

Commissions Schedule and Incentive Fees

Aetna Life Insurance Company does not offer commissions or incentive fees for Individual Conversion

business in New York.

Aetna Life Insurance Company New York Individual

G-1

Proprietary

Projected Loss Ratio

The New York Individual Conversion 2020 projected MBR for this filing is 91.24% following

the New York State methodology. The expected 2020 MLR for this filing, as defined by

PPACA and before any credibility adjustment, is 93.83%.

Individual Formula

(a) Member Months 375

(b) Earned Premium (pmpm) $966.46

(c) Incurred Claims (pmpm)(1) $881.83

(d) Medical Benefit Ratio (MBR) 91.24% = (c) / (b)

(e) Quality Improvement Activities (pmpm) $7.73 = (b) x 0.80 % (2)

(f) Taxes and Fees (pmpm) $18.37 = (b) x 1.90% (3)

(g) Adjusted Premium (pmpm) $948.09 = (b) - (f)

(h) Adjusted Claims (pmpm) $889.57 = (c) + (e)

(i) Medical Loss Ratio (MLR) 93.83% = (h) / (g)

(1) Incurred claims include an expected $26.11 risk adjustment transfer.

(2) Spending on quality improvement activities is estimated to be 0.80% of premium.

(3) Taxes and fees are estimated to be 1.90% of premium.

NOTE: Adjustments for QIA and taxes and fees are estimates based on historical experience and projected expenses.

Values reflect current actuarial projections and will differ from the final reported MLR.

Documents

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