HOrg02I Individual Health Organizations - Health Maintenance (HMO) HOrg02I.005A Individual - Preferred Provider (PPO)

Transcription

1 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: Project Name/Number: / Filing at a Glance Company: Product Name: State: TOI: Sub-TOI: Filing Type: UnitedHealthcare Benefits Plan of California 2016 Individual Exchange California HOrg02I Individual Health Organizations - Health Maintenance (HMO) HOrg02I.005A Individual - Preferred Provider (PPO) Rate Date Submitted: 04/30/2015 SERFF Tr Num: SERFF Status: State Tr Num: State Status: 2016 Individual Exchange UHLC Assigned In Progress Co Tr Num: 103 Implementation Date Requested: Author(s): Reviewer(s): Disposition Date: Disposition Status: Implementation Date: 01/01/2016 Brett Yost, Michelle Peters, Renee Jonet Wayne Thomas (primary), Debra Maus, Cabe Chadick, Harry Shi, Brent Cho, Simon Lo State Filing Description: PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

2 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: Project Name/Number: / General Information Project Name: Project Number: Requested Filing Mode: File & Use Explanation for Combination/Other: Submission Type: New Submission Status of Filing in Domicile: Date Approved in Domicile: Domicile Status Comments: Market Type: Individual Individual Market Type: Overall Rate Impact: Filing Status Changed: 04/30/2015 Deemer Date: Submitted By: Renee Jonet 2016 Individual Exchange State Status Changed: 04/30/2015 Created By: Brett Yost Corresponding Filing Tracking Number: PPA: Non-Grandfathered Immed Mkt Reforms PPA Notes: null Exchange Intentions: On Exchange Filing Description: We plan on offering the 2016 Standard Benefit Plan Designs that were distributed by the California Health Benefit Exchange. We have priced for the plan designs that had been presented and released at the March 5 Covered board meeting. Since that time, there are pending changes to these plan designs that have not yet been approved by the Board with additional proposed changes that were communicated April 24. Given the uncertainty of the final plan designs, we have not modified our pricing based on the proposed changes. Once the plans are finalized and approved (which is currently scheduled to take place at the May meeting), we may need to make adjustments to our plan rates. Company and Contact Filing Contact Information Renee Jonet, Actuarial Manager 3100 AMS Boulevard Green Bay, WI Filing Company Information UnitedHealthcare Benefits Plan of California 5995 Plaza Drive Cypress, (714) ext. [Phone] rjonet@unitedhealthone.com [Phone] [FAX] CoCode: Group Code: Group Name: FEIN Number: State of Domicile: California Company Type: State ID Number: Filing Fees Fee Required? Retaliatory? Fee Explanation: No No PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

3 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: Project Name/Number: / State Specific 2016 Individual Exchange Minimum % Change: the smallest 12-month, or annual, rate increase that any individual primary insured (individual insurance) or covered employee (group insurance) will receive, among all the insureds or covered employees renewing on the effective date of the proposed rate increase. The minimum should reflect all causes of premium increase to that insured or covered employee, including but not limited to attained age increases or geographic rate changes already built into the filed rate structure, as well as rate increases for new mandated benefits (e.g. PPA changes).: N/A. New Product. Maximum % Change: the largest 12-month, or annual, rate increase that any individual primary insured (individual insurance) or covered employee (group insurance) will receive, among all the insureds or covered employees renewing on the effective date of the proposed rate increase. The maximum should reflect all causes of premium increase to that insured or covered employee, including but not limited to attained age increases or geographic rate changes already built into the filed rate structure, as well as rate increases for new mandated benefits (e.g. PPA changes).: N/A. New Product. PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

4 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: 2016 Individual Exchange Project Name/Number: / Correspondence Summary Amendments Schedule Schedule Item Name Created By Created On Date Submitted Rate Rate Manual Brett Yost 07/08/ /08/2015 Supporting Premium Rate Information Brett Yost 07/08/ /08/2015 Document Supporting Actuarial Memorandum and Certifications Brett Yost 07/08/ /08/2015 Document Supporting Document Unified Rate Review Template Brett Yost 07/08/ /08/2015 PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

5 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: 2016 Individual Exchange Project Name/Number: / Amendment Letter Submitted Date: 07/08/2015 Comments: We have revised our rate filing as a result of Negotiation discussions with Covered California. Revised documents are attached. Changed Items: No Form Schedule Items Changed. Rate/Rule Schedule Item Changes Item No. Document Name Affected Form Numbers (Separated with Rate Action Rate Action Information Attachments Date Submitted commas) 1 Rate Manual New Rate Manual.pdf, 07/08/2015 By: Previous Version 1 Rate Manual New Rate Manual.pdf, 04/30/2015 By: Renee Jonet PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

6 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: 2016 Individual Exchange Project Name/Number: / Supporting Document Schedule Item Changes Satisfied - Item: Premium Rate Information Comments: Attachment(s): New Product Rate Filing Form.pdf Rates Template.xls Previous Version Satisfied - Item: Premium Rate Information Comments: Attachment(s): New Product Rate Filing Form.pdf Rates Template.xls Satisfied - Item: Comments: Attachment(s): Previous Version Satisfied - Item: Comments: Attachment(s): Actuarial Memorandum and Certifications Part III - Actuarial Memorandum.pdf Actuarial Memorandum and Certifications Part III - Actuarial Memorandum.pdf Satisfied - Item: Comments: Attachment(s): Previous Version Satisfied - Item: Comments: Attachment(s): Unified Rate Review Template Part I - URRT.xlsm Unified Rate Review Template Part I - URRT.xlsx PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

7 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: Project Name/Number: / 2016 Individual Exchange Post Submission Update Request Processed On 07/31/2015 Status: Created By: Processed By: Comments: Allowed Brett Yost Brent Cho Company Rate Information: Company Name:UnitedHealthcare Benefits Plan of California Field Name Requested Change Prior Value REQUESTED RATE: Projected Earned Premium: 37,715, ,542, Projected Incurred Claims: 33,337, ,929, Min: Max: 1, , Weighted Avg.: PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

8 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: 2016 Individual Exchange Project Name/Number: / Rate Information Rate data applies to filing. Filing Method: SERFF Rate Change Type: % Overall Percentage of Last Rate Revision: % Effective Date of Last Rate Revision: Filing Method of Last Filing: Company Rate Information Company Name: UnitedHealthcare Benefits Plan of California Company Rate Overall % Indicated Overall % Rate Written Premium Number of Policy Holders Affected Written Premium for Maximum % Change Minimum % Change Change: Change: Impact: Change for this Program: for this Program: this Program: (where req'd): (where req'd): New Product 0.000% 0.000% $0 0 $0 % % PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

9 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: Project Name/Number: / Rate Review Detail COMPANY: Company Name: HHS Issuer Id: PRODUCTS: 2016 Individual Exchange UnitedHealthcare Benefits Plan of California Product Name HIOS Product ID HIOS Submission ID Number of Covered 2016 Individual On-Exchange Product Trend Factors: , Lives FORMS: New Policy Forms: Affected Forms: Other Affected Forms: IEXPOL.I.16..COR, IEXPOL.I.16..CRE REQUESTED RATE CHANGE INFORMATION: Change Period: Annual Member Months: 0 Benefit Change: None Percent Change Requested: Min: 0.0 Max: 0.0 Avg: 0.0 PRIOR RATE: Total Earned Premium: 0.00 Total Incurred Claims: 0.00 Annual $: Min: 0.00 Max: 0.00 Avg: 0.00 REQUESTED RATE: Projected Earned Premium: 37,715, Projected Incurred Claims: 33,337, Annual $: Min: Max: 1, Avg: PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

10 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: 2016 Individual Exchange Project Name/Number: / Rate/Rule Schedule Item No. Schedule Item Document Name Affected Form Numbers (Separated with commas) Rate Action Rate Action Information Attachments Status 1 Rate Manual New Rate Manual.pdf, PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

11 UnitedHealthcare Benefits Plan of California Rate Manual For Policies Effective January 1, 2016 and Later

12 UnitedHealthcare Benefits Plan of California PREMIUM LCULATIONS Calculated Medical Premium For each person: Medical Premium(monthly) = RDC of Base Rate x Plan Factor x Age Factor x Tobacco Factor (if applicable) x Area Factor RDC = Round to 2 decimals Sum the Medical Premium for all persons to be covered. This Subtotal is the Total Monthly Premium. Note: Only the 3 oldest dependent children under the age of 21 will be included in the premium calculation. Total Quarterly Premium = Total Monthly Premium * 3

13 UnitedHealthcare Benefits Plan of California Monthly Base Rate $ Product Plan ID Deductible Coinsurance AV Calculated Metal/Cat Plan Factor Platinum 90 PPO $0 90% 88.5% Platinum Gold 80 PPO $0 80% 80.2% Gold Bronze 60 HSA PPO $4,500 60% 61.1% Bronze Bronze 60 PPO $6,000 0% 61.9% Bronze Silver 70 PPO $2,250 80% 70.4% Silver Minimum Coverage $6, % N/A Catastrophic 0.672

14 UnitedHealthcare Benefits Plan of California Age Tobacco Age Factor Factor <=

15 UnitedHealthcare Benefits Plan of California State Rating Area County Area Factor Alpine Del Norte Siskiyou Modoc Lassen Shasta Trinity Humboldt Tehama Plumas Rating Area 1 Nevada Sierra Mendocino Lake Butte Glenn Sutter Yuba Colusa Amador Calaveras Tuolumne Santa Cruz Rating Area 9 Monterey San Benito Madera Rating Area 11 Fresno Kings San Luis Obispo Rating Area 12 Santa Barbara Ventura Mono Rating Area 13 Inyo Imperial

16 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: 2016 Individual Exchange Project Name/Number: / Supporting Document Schedules Satisfied - Item: Comments: Attachment(s): Item Status: Status Date: Satisfied - Item: Comments: Attachment(s): Item Status: Status Date: Satisfied - Item: Comments: Attachment(s): Item Status: Status Date: Satisfied - Item: Comments: Attachment(s): Item Status: Status Date: Independent Actuarial Certification Act Opinion - April PPO Exchange Milliman.pdf Premium Rate Information New Product Rate Filing Form.pdf Rates Template.xls Actuarial Memorandum and Certifications Part III - Actuarial Memorandum.pdf Unified Rate Review Template Part I - URRT.xlsm PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

17 SERFF Tracking #: UHLC State Tracking #: Company Tracking #: 103 State: California Filing Company: UnitedHealthcare Benefits Plan of California TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005A Individual - Preferred Provider (PPO) Product Name: 2016 Individual Exchange Project Name/Number: / Attachment Rates Template.xls is not a PDF document and cannot be reproduced here. Attachment Part I - URRT.xlsm is not a PDF document and cannot be reproduced here. PDF Pipeline for SERFF Tracking Number UHLC Generated 08/04/ :23 PM

18 15800 Bluemound Road Suite 100 Brookfield, WI USA Tel Fax milliman.com Jason K. Sciborski, FSA, MAAA Principal and Consulting Actuary April 24, 2015 Actuarial Memorandum UnitedHealthcare Benefits Plan of California Individual PPO Policy Filing QUALIFITIONS I, Jason K. Sciborski, am a member of the American Academy of Actuaries and meet its qualification standards for actuaries issuing statements of actuarial opinions in the United States. This filing is prepared on behalf of UnitedHealthcare Benefits Plan of California (Company) to comply with California Insurance Code section (b) (2). It may not be appropriate for other purposes. I am affiliated with Milliman, Inc. (Milliman), an independent actuarial consulting firm that is not affiliated with, nor a subsidiary, nor in any way owned or controlled by a health plan, health insurer, or a trade association of health plans or insurers. SCOPE As a Consulting Actuary with Milliman, I have written this actuarial memorandum at the request of the Company to discuss the rate filing for its Individual PPO policies. The proposed rates included in this filing will be effective for new members enrolling on or after January 1, 2016 (on-exchange). Rate Increase The Company does not have any existing business in the individual market in California. This is an initial rate filing for new products thus no rate changes are being requested at this time. This Statement of Opinion complies with the Actuarial Standards of Practice 8 and 41, promulgated by the Actuarial Standards Board. RELIANCE I relied upon information provided by Michelle L. Peters, FSA, MAAA Regional Vice President and Actuary at the Company. While I reviewed the information for reasonableness, I did not audit the underlying data for correctness. Appendix A contains a Statement Regarding Accuracy and Completeness of the Underlying Data Sources provided to me as part of my review and forms a part of this opinion. If the data provided is later determined to be inaccurate, my conclusions could change. TESTING PROCEDURES AND SAMPLE RATE LCULATION As part of my review, I followed the testing procedures outlined in Appendix B. Offices in Principal Cities Worldwide

19 ACTUARIAL MEMORANDUM UnitedHealthcare Benefits Plan of California Individual PPO Policy Filing April 24, 2015 Page 2 of 4 Attachment C presents a sample calculation of the total monthly premium for an individual enrolling on January 1, The rate filing contains the premium details for each plan offering. OPINION ACTUARIALLY SOUND IN THE AGGREGATE In my opinion, the proposed premium rates are actuarially sound in the aggregate. The projected premium income, expected reinsurance cash flows and governmental risk adjustment cash flows are adequate to provide for all expected costs, including health benefits, health benefit settlement expenses, and marketing and administrative expenses as provided to me by the Company. OPINION REASONABLE PREMIUM RATES In my opinion, the proposed premium rates are reasonable. I based my opinion on the following factors: The expected individual loss ratio for the 12-month policy period beginning January 1, 2016 is 78.1%, based on the ratio of projected incurred claims divided by projected revenue. The projected loss ratio is unadjusted for items such as federal taxes, premium taxes, and quality initiatives that are allowed based on the NAIC s regulations. After adjusting for the allowable adjustments under PPA, the projected loss ratio is approximately 90.2%. The Federal Part III Actuarial Memorandum of the Company s filing contains more detail. The Company is pricing for a 4.1% pre-tax margin. The choice of assumptions is reasonable relating to unit cost increases, per capita utilization increases, and other assumptions based on the small group block of business used as the basis to project 2016 individual costs. The documentation included in this rate filing is adequate to determine the reasonableness of the proposed rates. The proposed rates result in premium differences between insureds that are permissible under applicable California and Federal law. The proposed rates are justified by credible experience data as the base (over 579,000 small group PPO member months) adjusted for anticipated changes between the small group and individual markets. The rate development is supported by substantial evidence of anticipated claims costs trends. I reviewed the medical trends used in the proposed premium development and found them to be reasonable. The medical trends are prepared by the Company s Healthcare Economics Department and reflect the following: Core Trend: 6.5% Trend Leveraging: 1.7% Total Pricing Trend: 8.3% This is an estimated crosswalk of trends (projected forward). In building their future trend assumptions, the Company s Healthcare Economics Department uses a static population.

20 ACTUARIAL MEMORANDUM UnitedHealthcare Benefits Plan of California Individual PPO Policy Filing April 24, 2015 Page 3 of 4 Due to the uncertainty around the individual market in 2016, the Company s actual results will almost certainly differ from the estimates in this letter. The most uncertain factor related to 2016 pricing is the risk adjustment mechanism and the impact of enrollment / lapsation on overall morbidity in the market due to the Affordable Care Act. The Company assumed the average risk of those who enroll in these product offerings will be about the same as the California state average (with respect to the risk adjustment component of the A as a percent of total premium). The impact of the mandated age curve and the removal of medical underwriting were estimated and are included in the proposed rates. OTHER FACTORS In addition, I reviewed the items listed below: Return on Equity (ROE) is not considered explicitly in the rate development process and thus was not relied upon in my review. Instead, loss ratios and pre-tax margin were considered as noted above. The Company s statutory capital and surplus level and dividend history for the past four years ending 2013 is as follows: Statutory Capital and Surplus 2010 $4,021,961, $4,421,635, $4,711,885, $5,039,492,066 Dividend History 2010 $1,773,526, $2,200,000, $2,234,000, $2,137,000,000 I reviewed the statutory capital and surplus levels and the dividend history of the Company, but I did not rely upon it since it was not considered explicitly in the rate development process. Please note that the values listed above reflect nationwide data for UnitedHealthcare Insurance Company and are not specific to UnitedHealthcare s California block of business. The employee and executive compensation is part of the overall administrative expense assumed in the premium development. I reviewed the compensation levels of the six highest paid UnitedHealth Group executives listed below but offer no opinion on the appropriateness of the compensation levels, since it was not considered explicitly in the rate development process (i.e., it is reflected in the total administrative cost) Base Salary Non-Equity Incentive Compensation Total Compensation Stephen Hemsley $1,300,000 $3,100,000 $4,400,000 David Wichmann 892,885 2,608,526 3,501,411 Gail Boudreaux 892,885 2,008,526 2,901,411 Larry Renfro 892,885 3,858,526 4,751,411 Marianne Short 721, ,384 1,711,538

21 ACTUARIAL MEMORANDUM UnitedHealthcare Benefits Plan of California Individual PPO Policy Filing April 24, 2015 Page 4 of 4 Appendix D contains Schedule Y from UnitedHealthcare Insurance Company s 2011, 2012, and 2013 annual statements. Schedule Y provides information regarding the nature and amount of transactions between the Company and its affiliates. I reviewed this information but did not make any determinations from it since these affiliate transactions do not directly impact the Company s PPO rates referenced in this filing (and thus are not explicitly considered in the rate development process). Respectfully Submitted, Jason K. Sciborski Member of the American Academy of Actuaries April 24, 2015

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23 Appendix B Description of Testing Procedures Under my direction, we reviewed the rating process performed by UnitedHealthcare s Actuarial staff including: 1. Claims cost trend rates and development of anticipated unit cost and utilization increases. Pricing trend follows a projected average core trend (utilization and cost trend). The assumed trend is reasonable, given the Company s explanation of their trend development and the claim experience on their small group block of business. 2. Claims and enrollment base period data collection process and reconciliation to internal financial statements. The information tied to financial summaries for total claims, premium, and enrollment within small tolerances for UnitedHealthcare s small group block (which was used as the basis for the individual rate development). The data collected was for incurred dates of 7/1/2013-6/30/2014 with run out for two additional months. A provision for incurred but not paid claims beyond the two month run out period consistent with past rate development was held to complete the base period. 3. Development of projected claims. Using information from items 1 and 2 above, we applied the assumptions in the filing to validate the cost projections for the base experience used to develop the proposed rates. The claim projection includes fee-for-service medical services and prescription drug costs. Projected claims were then adjusted to account for the new individual product offering. 4. Benefit plan testing. The Company is only offering benefit plans outlined by Covered California. Thus we took the Actuarial Value of these benefits calculated by Covered California as a given. We also performed an independent review of the Company s proposed benefit plan rating factors and found them to be reasonable in relation to the benefits offered. 5. UnitedHealthcare Benefits Plan of California uses table rates for all individuals that are included with this filing. Appendix C provides a rate example for a sample individual. 6. Proposed rates based on comparison of projected loss ratio to target loss ratio. The proposed rates are established to meet the medical loss ratio targets for the projection period. April 24, 2015 Milliman

24 Appendix C UnitedHealthcare Benefits Plan of California Individual Rate Filing, January 1, 2016 Sample Calculation of Monthly Premium Base Rate Age Tobacco Area Age Factor Factor Area Factor <= Rating Area Rating Area Plan Plan ID Metal / Cat Plan Factor Rating Area Platinum 90 PPO Platinum Rating Area Gold 80 PPO Gold Rating Area Bronze 60 HSA PPO Bronze Rating Area Bronze 60 PPO Bronze Rating Area Silver 70 PPO Silver Rating Area Minimum Coverage Catastrophic Rate Formula Rate = Base Rate x Plan Factor x Age Factor x Tobacco Factor x Area Factor Rate Sample Sample rate for Gold 80 PPO plan for a 40 year-old smoker in Rating Area 12 for a January 1, 2016 effective date = $ x x x x = $ /24/2015 Milliman

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29 ,*!"# &!"# *, - ()./ ' )) ) // +! 0!1 2$%! /' 7' '# ' !1 2$%!3 # +# # ' ; 7 & +%1 2(#% %#3 $!%! '() % ' $+ " % :!"" #$!!% &'' ( ) #$ #$!!% &'*"' ( )!"" #$ #$ #$ (" +,"!%"-)*"' ( ) #$ #$ #$ ("." -" #$ #$ ("."-"- #$ #$ ("."/" ("."0') #$ #$ #$ "1.)'"" ' #$ #$ 2. &"!3!-. 4-"' (&(-!'+ )!, #$ #$ #$ (&(-!'56 '' ( ) #$ #$ #$ (&(-!'%-.-! ' ( ) #$ #$ (&(-!'7"''"' ( ) "-'3!-. #$ #$!! 8 -"& %&"' #$ #$ 92%&"' 9-!2"-&",'!"" #$ #$ #$ #$ 9-!2"-&",'!!""' #$ #$ 9-!2"-&",' :!-"-%)'-(' ; ("!)3!-. %&"' ; ("!)3(3'" ;4<3: *534; <=4!,<!;" "! -"!,<!' ( ) #$ #$ #$ 3!-.-' #$ #$ #$ 3!-.--"- #$ #$ 3!-.-0') #$ #$ 3!-.- #$ #$ 3!-.! &, #$ #$ #$ #$ 3!-.!!"' %<% *""-: '- *""-3!-. + +%*",3!-.' ( ) #$ #$ #$

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

31 ,*<!"# &!"# *, - ()./ ' )) ) // +! 0!1 2$%! /' 7' '# ' !1 2$%!3 # +# # ' ; 7 & +%1 2(#% %#3 $!%! '() % ' $+ " % :!! " #$% "&! & && #$%'()* & #+% & &! &"& "! #,-# " " " #$./!!! ""! #00-12 "! & &&! & #00-1./ 33 &! &! " & #00-1 &"""! " &! &&! " " " " #-01 ""! &"! " " & "! " "! && "! & & #-01! "! "! &&& #-01'( )*! &! "&&! &! "& "& #-01 4%51!! "& & #60! & &&! "! &! &"" #7! "&"! &! ""! & #*! &!! "&! & ## ""!! " & #8#! & &!! &"! & & #,9 "! &!! "&&! "" & #!! "! &! #:-*13#! "! &"! &! & "" & #3- &&&!! &&&! " &" #;! ""! &"! &"! " #'(<9#! & ""! "! &! "&& #'(;/! " "! " " "! & "& #'()* &! &! #' "! "" &! &! &"! & & #2! &! "! & &"! #2*0 "&! &! &&! "! & && #29 &!!! &! "&& #1%! ""! & ""! "" && #+-! " " "! "! "" " " #./ &! & &! &"! &! & #;#! &"&! &""!! ""& #;##! &! "! &"&&! & & #;#(! "! &"!! " "

32 ,*=&!"# &!"# *, - ()./ ' )) ) // +! 0!1 2$%! /' 7' '# ' !1 2$%!3 # +# # ' ; 7 & +%1 2(#% %#3 $!%! '() % ' $+ " % :!"!! #$%&' (%))* (%!*+,' $%&' -."' ///"+0 ///"+ 1)*, <<<

33 Appendix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

34 Appendix D-3,<!"#$!!"#$ *, - ()!.'!)) )!/! +" 0!"1 2%&"3!!4 5! 6/'! 7'!'$ '23 8 /" /" +! 9!"1 2%&"3 /" $ +$! $!!' ; 7!+&1 2($&3!!1! + 612&$3 % "& "!'() &!'! %+ #!&! :!! " # # "!$ %& ## ## # # &' (" )* )#* )#* # # &' (+"),* )##* # )#* )* # &' (+")-.* )* )* # )* )#* # &' (+")-/* )#* )#* +!'!0!'(" 1 )#* )#* )#* # # +!'!0!'2"" 1 # # +!'! '2!3 )* )#* )* +!'! ' ( )#* # )#* # # +!'! '-4( )#* # )* # +1"!!"! ',&"00 )#* # )#* )* ## +'(+" (!$ )* )* # +'(+"5(!6 ## ## # # +'(+" )###* )* )* # +!5(!-7 #!(0!'" 1 )#* )* # )* #! 5(!+ (" 7"5(!2""!" # # # 84! +!'! # 8 '!'! )* )* )#* # 8!!" 1 )* )* )##* )#* # # # 8!!0!'" 1 '-7 / )* )* 8!" + '97 )#* )#* )* )* ## 8!" + '!2 )* )#* )* )* # 8!(4! ### ### 8!(4!" ## )* # #### 8!(6 ( ## # # 8!('!" ',&" )* )* # )##* )* # 8!(!1+ '! )#* )#* )* # 8!(!1+ ',&" 00 )* # )* )* # 8!(!1+ )#* ## )#* )#* # 8!(" 1 )* )#* )* )*

35 Appendix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

36 STATE OF LIFORNIA DEPARTMENT OF MANAGED HEALTH RE Shelley Rouillard, Director 980 Ninth Street, Suite 500 Sacramento, Edmund G. Brown Jr., Governor California New Product Rate Filing Form For Individual and Small Group Health Insurance New Product Rates (do not use this form for initial filings for existing product rates) The rate filing submission for new product rates should include: 1) This form 2) A spreadsheet with rate information responsive to Question 7 below. 3) A benefit grid describing the benefits of the new product. 4) A spreadsheet with rate information for the plan s existing product with the closest benefit structure. 5) A benefit grid describing the benefits of the plan s existing product with the closest benefit structure. 6) A description of how the new product rates were developed. 7) An actuarial certification. 1) Company Name: 2) Number of plan contract forms covered by the filing: 3) Plan contract form numbers covered by the filing: List all of the plan contract form numbers covered by this filing, and all product names associated with each plan contract form number, in the spreadsheet submitted in response to Question 7. 4) Product types covered by the filing. Select from the following: HMO (Health Maintenance Organization) PPO (Preferred Provider Organization) EPO (Exclusive Provider Organization) POS (Point of Service) FFS (Fee for Service) Other (describe): 1

37 5) Segment type. One of the following: Small Group (2-50 employee) Individual Note: Small Group and Individual filings should not be combined within a single filing. 6) Plan type. One of the following: for-profit company, not-for-profit company 7) Annual Rate For-profit company Not-for profit company In a separate spreadsheet, for each product included in the filing, show the proposed annual premium rates for each rating cell. 8) Review category: One of the following: Initial Filing for New Product Resubmission Resubmissions should be submitted through SERFF under the same state filing number and SERFF tracking number assigned to the original submission of this filing. Do not submit resubmissions as a new filing. 9) Submit the required actuarial certification, under the Supporting Documentation tab in SERFF. Submitted 10) Comments. Place any needed comments here. 2

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