I am a member of the American Academy of Actuaries. To the best of my knowledge and judgment,
1. This rate filing is in compliance with the applicable laws and regulations concerning premium rate development in this state and the benefits are reasonable in relationship to premiums.
2. The projected index rate is:
a. In compliance with all applicable State and Federal Statutes and Regulations.
b. Developed in compliance with the Actuarial Standards of Practice.
c. Reasonable in relation to the benefits provided and the population anticipated to be covered.
d. Neither excessive nor deficient.
3. 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.
4. 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. To the best of my knowledge, the percent of total premium that represents EHB’s is 100%.
5. The HHS AV Calculator was used to determine the AV Metal Values for all plans shown in Worksheet 2 of the Part I Unified Rate Review Template except for those documented in this memorandum. The AV values for those documented in the memorandum were developed based on one of the acceptable alternative methods and are in accordance with generally accepted actuarial principles and methodologies.
Brent Wiskirchen, FSA, MAAA _________ _____
Associate Actuary – Reform Pricing 10/2014
A Pooled 2013 Per Member Per Month Allowed Claims - State $286.76
B 2013 Per Member Per Month Allowed Claims - Manual $381.91
C Credibility of State Experience 72%
D Credibility Adjusted PMPM Allowed Claims $313.18 D = A x C + (B x (1-C))
E Annual Trend on an Allowed Claim Basis 9.5%
F 24 Months of Trend from Midpoint of 2013 to Midpoint of 2015 1.199 F = (1+E) ^ 2
G Adjust Experience to 2013 Market Risk 1.261
H Adjust Experience to 2015 Market Risk 1.350
I Cost of Essential Benefits Not covered within Experience Data 1.083
J Adjust to Account for Additonal USPSTF Preventative Items 1.010
K Adjust to Account for the Pent Up Demand of Uninsured 1.005
L Adjust Experience for Expected Change in Network Discounts 1.008
M Adjusted to 2015 PMPM Allowed Claims $707.80 M = D x F x G x H x I x J x K x L
N Adjust Experience for Increased Utilization due to Decreased Cost Sharing 1.027
Age Adjustment
O 2013 Average Age Curve Factor 1.416 2013 Average Age Rating Factor Weighted by Age Membership Split
P 2015 Average Age Curve Factor 1.451 2015 Average Age Rating Factor Weighted by Age Membership Split
Q Age Adjustment Factor 1.025 Age Calibration Factor Applied to the 2015 Projected Index Rate = P / O
Geographic Adjustment
R Geographic Shift Factor 1.001 Shift in Projected Distribution of Membership by Geographic Area
2015 Projected Index Rate Total PMPM Allowed Claims; Excluding Reinsurance and Risk Adjustment Transfers $745.83 2015 Index Rate = M x N x Q x R / T
S Market-wide Adjustment for Expected Reinsurance 0.877 Net of Reinsurance Contribution
T Market-wide Adjustment for Expected Risk Adjustment 1.000 Pricing to a 1.0 Risk Score
U Market-wide Adjustment for Exchange User Fee 1.000 Not on Exchange
MARKET ADJUSTED INDEX RATE 2015 PMPM Allowed Claims adjusted for Reinsurance, Risk Adjustment, and Exchange Fees $654.36 Market Adjusted Index Rate = M x N x Q x R x S x T x U BRONZE MARKET ADJUSTED INDEX RATE 2015 PMPM Allowed Claims; excludes utilization adjustment (applied at plan level) $637.16 Bronze Market Adjusted Index Rate = M x Q x R x S x T x U
V Age Calibration Factor 0.689 Calibration factor to 21 year old (standard age curve factor of 1.0) = 1 / P
W Geo Calibration Factor 1.000
WY
Age and Geographic Calibration Factors
Appendix B: Trend Exhibit
Benefit Category
Utilization (Increase in Number of Services)
Severity (Increase in Cost per Service)
Allowed Trend (Utilization * Severity)
Professional 1.05 1.01 1.055
Inpatient Hospital 1.07 1.01 1.086
Outpatient Hospital 1.12 1.01 1.131
Other Medical 1.07 1.22 1.313
Prescription Drug 1.08 1.02 1.109
Total 1.08 1.02 1.097
The above exhibit represents the three year average for 2010, 2011, and 2012.
Given this information, we are proposing an allowed trend of 9.5%.
Proposed Trend Benefit Category
Utilization (Increase in Number of Services)
Severity (Increase in Cost per Service)
Allowed Trend (Utilization * Severity)
Professional 1.05 1.01 1.053
Inpatient Hospital 1.07 1.01 1.084
Outpatient Hospital 1.12 1.01 1.129
Other Medical 1.07 1.22 1.310
Prescription Drug 1.08 1.02 1.107
Total 1.08 1.02 1.095
Historical levels
2012 over 2011 1.08 1.02 1.11
2011 over 2010 1.09 1.01 1.10
2010 over 2009 1.06 1.01 1.08
3 year average 1.08 1.02 1.10
2 year average 1.09 1.02 1.10
Metal Level Plan Plan Type Deductible Coinsurance Total OOP OV Copay OV: Primary/Specialty OV Limit ER Access Fee D/X/L Benefit Prescriptions Rx Ded HSA Actuarial Value
Bronze 1 Non 1-Ded $6,000 100% $6,000 None N/A N/A $100 None Integrated Integrated Y 59.2%
AV: 60% 2 Non 1-Ded $5,000 75% $6,350 $35 Primary/Specialty 4 $100 None Integrated Integrated N 61.3%
3 Non 1-Ded $2,600 50% $6,350 None N/A N/A $100 None Integrated Integrated Y 61.4%
4 Non 1-Ded $5,000 75% $6,350 None N/A N/A $100 None 25/50/75 $500 Brand N 60.9%
5 Non 1-Ded $3,500 50% $6,350 None N/A N/A $100 None 25/50/75 $500 Brand N 61.8%
Silver 1 Non 1-Ded $3,500 100% $3,500 None N/A N/A $100 None Integrated Integrated Y 68.8%
AV: 70% 2 Non 1-Ded $2,000 50% $6,350 $30 Primary/Specialty 10 $100 None 15/35/60 None N 70.1%
3 Non 1-Ded $1,250 50% $5,000 None N/A N/A $100 $500 Integrated Integrated N 68.8%
4 Non 1-Ded $1,850 50% $6,350 $30 Primary/Specialty 10 $100 $500 15/35/60 None N 71.9%
Gold 1 Non 1-Ded $2,000 100% $2,000 None N/A N/A $100 None Integrated Integrated N 78.8%
AV: 80% 2 Non 1-Ded $0 75% $6,350 $25 Primary/Specialty Unlimited $100 None 15/35/60 None N 81.7%
Platinum 1 Non 1-Ded $950 100% $950 None N/A N/A $100 None Integrated Integrated N 88.2%
AV: 90% 2 Non 1-Ded $0 75% $2,000 $25 Primary/Specialty Unlimited $100 None 10/30/50 None N 88.1%
Catastrophic 1 Non 1-Ded $6,600 100% $6,600 $0 (First Dollar) Primary 3 $100 None Integrated Integrated N 59.5%
Bronze 1 1-Ded $5,500 100% $5,500 None N/A N/A $100 None Integrated Integrated Y 58.5%
AV: 60% 2 1-Ded $3,000 50% $6,000 None N/A N/A $100 None Integrated Integrated Y 58.9%
Drug Design
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $6,000.00
Coinsurance (%, Insurer's Cost Share) 100.00%
OOP Maximum ($) $6,000.00
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) Specialist Visit
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 100% $0.00 100% $0.00
Laboratory Outpatient and Professional Services X-rays and Diagnostic Imaging
Skilled Nursing Facility
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services
Drugs Generics
Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):
Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 59.2%
Metal Tier: Bronze
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $5,000.00
Coinsurance (%, Insurer's Cost Share) 75.00%
OOP Maximum ($) $6,350.00
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) $35.00
Specialist Visit $35.00
Mental/Behavioral Health and Substance Abuse Disorder Outpatient
Services $35.00
Imaging (CT/PET Scans, MRIs) Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Preventive Care/Screening/Immunization 100% $0.00 100% $0.00
Laboratory Outpatient and Professional Services X-rays and Diagnostic Imaging
Skilled Nursing Facility
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services
Drugs Generics
Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10): 2 Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 62.0%
Metal Tier: Bronze
Impact of 2 visit limit on Specialty copay: -0.70%
Ending AV 61.3%
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $2,600.00
Coinsurance (%, Insurer's Cost Share) 50.00%
OOP Maximum ($) $6,350.00
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) Specialist Visit
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 100% $0.00 100% $0.00
Laboratory Outpatient and Professional Services X-rays and Diagnostic Imaging
Skilled Nursing Facility
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services
Drugs Generics
Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):
Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 61.4%
Metal Tier: Bronze
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $5,000.00 $500.00 Coinsurance (%, Insurer's Cost Share) 75.00% 100.00%
OOP Maximum ($) OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) Specialist Visit
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 100% $0.00 100% $0.00
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
Drugs
Generics $25.00
Preferred Brand Drugs 61%
Non-Preferred Brand Drugs 61%
Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):
Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 60.9%
Metal Tier: Bronze
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
$6,350.00
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $3,500.00 $500.00 Coinsurance (%, Insurer's Cost Share) 50.00% 100.00%
OOP Maximum ($) OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) Specialist Visit
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 100% $0.00 100% $0.00
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
Drugs
Generics $25.00
Preferred Brand Drugs 61%
Non-Preferred Brand Drugs 61%
Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):
Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 61.8%
Metal Tier: Bronze
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
$6,350.00
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $3,500.00
Coinsurance (%, Insurer's Cost Share) 100.00%
OOP Maximum ($) $3,500.00
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) Specialist Visit
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 100% $0.00 100% $0.00
Laboratory Outpatient and Professional Services X-rays and Diagnostic Imaging
Skilled Nursing Facility
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services
Drugs Generics
Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):
Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 68.8%
Metal Tier: Silver
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $2,000.00
Coinsurance (%, Insurer's Cost Share) 50.00%
OOP Maximum ($) $6,350.00
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) $30.00
Specialist Visit $30.00
Mental/Behavioral Health and Substance Abuse Disorder Outpatient
Services $30.00
Imaging (CT/PET Scans, MRIs) Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Preventive Care/Screening/Immunization 100% $0.00 100% $0.00
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
Drugs
Generics $15.00
Preferred Brand Drugs $35.00
Non-Preferred Brand Drugs $60.00
Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10): 6 Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 70.1%
Metal Tier: Silver
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $1,250.00
Coinsurance (%, Insurer's Cost Share) 50.00%
OOP Maximum ($) $5,000.00
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) Specialist Visit
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 100% $0.00 100% $0.00
Laboratory Outpatient and Professional Services X-rays and Diagnostic Imaging
Skilled Nursing Facility
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services
Drugs Generics
Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):
Output
Status/Error Messages: Error: Result is outside of +/- 2 percent de minimis variation.
Actuarial Value: 67.3%
Metal Tier:
DXL 1.5%
Total 68.8%
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $1,850.00
Coinsurance (%, Insurer's Cost Share) 50.00%
OOP Maximum ($) $6,350.00
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) $30.00
Specialist Visit $30.00
Mental/Behavioral Health and Substance Abuse Disorder Outpatient
Services $30.00
Imaging (CT/PET Scans, MRIs) Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Preventive Care/Screening/Immunization 100% $0.00 100% $0.00
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
Drugs
Generics $15.00
Preferred Brand Drugs $35.00
Non-Preferred Brand Drugs $60.00
Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10): 6 Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 70.3%
Metal Tier: Silver
DXL 1.6%
Total 71.9%
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
Tier 1 Tier 2
HSA/HRA Options Narrow Network Options
Annual Contribution Amount: 1st Tier Utilization:
2nd Tier Utilization:
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier
Medical Drug Combined Medical Drug Combined
Deductible ($) $2,000.00
Coinsurance (%, Insurer's Cost Share) 100.00%
OOP Maximum ($) $2,000.00
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of Benefit Subject to
Deductible?
Emergency Room Services $100.00
All Inpatient Hospital Services (inc. MHSA)
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) Specialist Visit
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 100% $0.00 100% $0.00
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
Drugs Generics
Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs (i.e. high-cost)
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?
# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):
Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 78.8%
Actuarial Value: 78.8%