Filing at a Glance - State of Reform€¦ · Filing at a Glance Company: Group Health Cooperative Product Name: GHC - Individual Rate Filing - 1-2015 State: Washington TOI: HOrg02I

Filing at a Glance

Company: Group Health Cooperative

Product Name: GHC - Individual Rate Filing - 1-2015

State: Washington

TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)

Sub-TOI: HOrg02I.005C Individual - Other

Filing Type: Rate

Date Submitted: 04/28/2014

SERFF Tr Num: GHCC-129490995

SERFF Status: Assigned

State Tr Num: 270077

State Status: Review Pending

Co Tr Num: GHC-IF-RATE-201501

ImplementationDate Requested:

01/01/2015

Author(s): Ben Choi, Rebecca Stob, Janice Cecotti, Mark Ackerman, Dan Jordan

Reviewer(s): Shiraz Jetha (primary)

Disposition Date:

Disposition Status:

Implementation Date:

State Filing Description:

SERFF Tracking #: GHCC-129490995 State Tracking #: 270077 Company Tracking #: GHC-IF-RATE-201501

State: Washington Filing Company: Group Health Cooperative

TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005C Individual - Other


Project Name/Number: /

PDF Pipeline for SERFF Tracking Number GHCC-129490995 Generated 05/05/2014 04:30 PM

General Information

Company and Contact

Project Name: Status of Filing in Domicile:

Project Number: Date Approved in Domicile:

Requested Filing Mode: Review & Approval Domicile Status Comments:

Explanation for Combination/Other: Market Type: Individual

Submission Type: New Submission Individual Market Type: Individual

Overall Rate Impact: 11.2% Filing Status Changed: 04/29/2014

State Status Changed: 04/29/2014

Deemer Date: Created By: Ben Choi

Submitted By: Janice Cecotti Corresponding Filing Tracking Number:

PPACA: Non-Grandfathered Immed Mkt Reforms

PPACA Notes: null

Exchange Intentions: Exchange and Outside Market

Filing Description:

Component ID /Plan Name / AV80473WA0800006 /Core3 Gold -15 / 81.2%80473WA0800001 /Core3 Silver -15 / 71.1%80473WA0790001 /Core3 Bronze - 15 / 61.9%80473WA0780001 /Core Bronze H.S.A. -15 / 60.2%80473WA0810001 /Core Basics Plus -15 / 59.8%80473WA0840002 /Core3 Gold -15 / 81.2%80473WA0840001 /Core3 Silver -15 / 71.1%80473WA0830001 /Core3 Bronze-15 / 61.9%80473WA0820001 /Core Bronze H.S.A. -15 / 60.2%

Experience Rate Change = 8.7%Benefit Change = 2.3%Overall Rate Change = 11.2%

Benefit Changes by PlanAll 2014 plans have been eliminated and replaced with new 2015 plans.

Filing Contact InformationBen Choi, [email protected]

320 Westlake Ave N, Suite 100

Seattle, WA 98109

206-448-5774 [Phone]







Filing Fees

State Specific

Filing Company InformationGroup Health Cooperative

12401 E Marginal Way S

Tukwila, WA 98168

(206) 901-4593 ext. [Phone]

CoCode: 95672

Group Code: 1185

Group Name:

FEIN Number: 91-0511770

State of Domicile: Washington

Company Type:

State ID Number: 554

Fee Required? No

Retaliatory? No

Fee Explanation:

If you are filing a Healthcare or Disability filing, is the Co Tracking # field populated on the General Information Tab? If no,your filing will be rejected. (yes/no): yesForm Tab Only - Are the Form # and Form Description fields populated corresponding to the attached form? (yes/no): NAIf your are submitting a File and Use product, have you populated the Implementation Date field? (yes/no): NA







Rate Information Rate data applies to filing.

Filing Method: Review & Approval

Rate Change Type: Increase

Overall Percentage of Last Rate Revision: 0.000%

Effective Date of Last Rate Revision: 01/01/2014

Filing Method of Last Filing: Review & Approval

Company Rate Information

Company

Name:

Company

Rate

Change:

Overall %

Indicated

Change:

Overall %

Rate

Impact:

Written

Premium

Change for

this Program:

Number of Policy

Holders Affected

for this Program:

Written

Premium for

this Program:

Maximum %

Change

(where req'd):

Minimum %

Change

(where req'd):

Group HealthCooperative

Increase 11.200% 11.200% $7,819,889 24,079 $69,566,816 20.400% -4.000%







Rate Review Detail

COMPANY:Company Name: Group Health Cooperative

HHS Issuer Id: 80473

PRODUCTS:

Product Name HIOS Product ID HIOS Submission ID Number of Covered

LivesGroup Health Cooperative Individual &Family Catastrophic Exchange

80473WA081 NA 53

Group Health Cooperative Individual &Family Core HSA Direct

80473WA082 NA 6614

Group Health Cooperative Individual &Family Core HSA Exchange

80473WA078 NA 2320

Group Health Cooperative Individual &Family Core3 Bronze Direct

80473WA083 NA 6614

Group Health Cooperative Individual &Family Core3 Bronze Exchange

80473WA079 NA 2380

Group Health Cooperative Individual &Family Core3 Direct

80473WA084 NA 5604

Group Health Cooperative Individual &Family Core3 Exchange

80473WA080 NA 10966

Trend Factors: 8.6% Annual Trend

FORMS:New Policy Forms: CA-4100, CA-4109, CA-4096, CA-4101, CA-395715, CA-395315, CA-395915

Affected Forms:

Other Affected Forms:

REQUESTED RATE CHANGE INFORMATION:Change Period: Annual

Member Months: 270,003

Benefit Change: Increase

Percent Change Requested: Min: -4.0 Max: 20.4 Avg: 11.2

PRIOR RATE:Total Earned Premium: 147,218,212.00

Total Incurred Claims: 115,313,183.00

Annual $: Min: 100.99 Max: 1,061.34 Avg: 355.07

REQUESTED RATE:Projected Earned Premium: 163,766,763.00

Projected Incurred Claims: 129,625,148.00

Annual $: Min: 101.79 Max: 1,129.74 Avg: 394.99







Rate/Rule Schedule







Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 GHC I&F Exchange CoreBronze HSA - 15

CA-4100 New Rate Schedule.pdf,Rate ScheduleDuplicate.xlsx,

2 GHC I&F Exchange CoreBronze HSA AmericanIndian/Alaskan Native LimitedCost Share - 15

CA-4109 New

3 GHC I&F Exchange Core3Bronze - 15

CA-4096 New

4 GHC I&F Exchange Core3Bronze AmericanIndian/Alaskan Native No CostShare - 15

CA-4101 New

5 GHC I&F Exchange Core3Bronze AmericanIndian/Alaskan Native LimitedCost Share - 15

CA-4107 New

6 GHC I&F Exchange Core3Silver - 15

CA-4102 New

7 GHC I&F Exchange Core3Silver 94 - 15

CA-4105 New


CA-4104 New


CA-4103 New

10 GHC I&F Exchange Core3Silver American Indian/AlaskanNative Limited Cost Share - 15

CA-4110 New

11 GHC I&F Exchange Core3Gold - 15

CA-4106 New

12 GHC I&F Exchange Core3Gold American Indian/AlaskanNative Limited Cost Share - 15

CA-4108 New

13 GHC I&F Exchange CoreBasics Plus - 15

CA-395715 New

14 GHC I&F Core Bronze HSA -15

CA-395315 New







15 GHC I&F Core3 Bronze - 15 CA-4095 New16 GHC I&F Core3 Silver - 15 CA-395915 New17 GHC I&F Core3 Gold - 15 CA-4113 New







Tobacco User Status: Non-Tobacco User Area: 1

Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315

Product ID: 80473WA080 80473WA080 80473WA079 80473WA078 80473WA081 80473WA084 80473WA084 80473WA083 80473WA082Metal Level: Gold Silver Bronze Bronze Catastrophic Gold Silver Bronze Bronze

Plan Name: Core3 Gold -15 Core3 Silver -15 Core3 Bronze - 15Core Bronze H.S.A. -15 Core Basics Plus -15 Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15

Core Bronze H.S.A. -15

Plan ID: 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001Exchange Plan?: Yes Yes Yes Yes Yes No No No NoAge Band

0-20* $189.52 $155.43 $127.21 $122.19 $106.47 $192.17 $157.60 $128.98 $122.5021 $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.9122 $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.9123 $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.9124 $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.9125 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6826 $305.63 $250.65 $205.15 $197.04 $171.70 $309.90 $254.15 $208.00 $197.5427 $312.79 $256.53 $209.95 $201.66 $175.72 $317.16 $260.10 $212.87 $202.1728 $324.43 $266.07 $217.77 $209.16 $182.26 $328.96 $269.78 $220.80 $209.6929 $333.98 $273.91 $224.18 $215.32 $187.63 $338.65 $277.72 $227.30 $215.8730 $338.76 $277.82 $227.38 $218.40 $190.31 $343.49 $281.70 $230.55 $218.9531 $345.92 $283.70 $232.19 $223.02 $194.34 $350.75 $287.65 $235.42 $223.5832 $353.08 $289.57 $237.00 $227.63 $198.36 $358.01 $293.61 $240.30 $228.2133 $357.56 $293.24 $240.00 $230.52 $200.88 $362.55 $297.33 $243.34 $231.1134 $362.33 $297.16 $243.21 $233.60 $203.56 $367.40 $301.30 $246.59 $234.1935 $364.72 $299.12 $244.81 $235.14 $204.90 $369.82 $303.29 $248.22 $235.7436 $367.11 $301.08 $246.41 $236.68 $206.24 $372.24 $305.27 $249.84 $237.2837 $369.50 $303.03 $248.02 $238.22 $207.58 $374.66 $307.26 $251.47 $238.8238 $371.88 $304.99 $249.62 $239.76 $208.92 $377.08 $309.24 $253.09 $240.3739 $376.66 $308.91 $252.83 $242.84 $211.61 $381.92 $313.22 $256.34 $243.4540 $381.44 $312.83 $256.03 $245.91 $214.29 $386.76 $317.19 $259.59 $246.5441 $388.60 $318.70 $260.84 $250.53 $218.31 $394.03 $323.14 $264.47 $251.1742 $395.46 $324.33 $265.45 $254.96 $222.17 $400.99 $328.85 $269.14 $255.6143 $405.01 $332.16 $271.86 $261.12 $227.54 $410.67 $336.79 $275.64 $261.7844 $416.95 $341.95 $279.87 $268.81 $234.24 $422.78 $346.72 $283.76 $269.4945 $430.98 $353.46 $289.29 $277.86 $242.12 $437.00 $358.39 $293.31 $278.5646 $447.69 $367.17 $300.51 $288.63 $251.51 $453.95 $372.29 $304.69 $289.3647 $466.50 $382.59 $313.13 $300.76 $262.08 $473.01 $387.92 $317.48 $301.5248 $487.99 $400.21 $327.55 $314.61 $274.15 $494.80 $405.79 $332.11 $315.4149 $509.18 $417.59 $341.78 $328.27 $286.05 $516.29 $423.41 $346.53 $329.1050 $533.05 $437.17 $357.80 $343.67 $299.47 $540.50 $443.27 $362.78 $344.5451 $556.63 $456.51 $373.63 $358.87 $312.71 $564.41 $462.87 $378.83 $359.7852 $582.60 $477.81 $391.06 $375.61 $327.30 $590.74 $484.47 $396.50 $376.5653 $608.86 $499.35 $408.69 $392.54 $342.06 $617.37 $506.31 $414.37 $393.5454 $637.22 $522.60 $427.72 $410.82 $357.99 $646.12 $529.89 $433.67 $411.8655 $665.57 $545.85 $446.75 $429.10 $373.92 $674.87 $553.46 $452.97 $430.1956 $696.31 $571.07 $467.39 $448.92 $391.19 $706.04 $579.03 $473.89 $450.0657 $727.35 $596.52 $488.22 $468.93 $408.62 $737.51 $604.84 $495.01 $470.1258 $760.48 $623.69 $510.46 $490.29 $427.24 $771.11 $632.39 $517.56 $491.5359 $776.90 $637.16 $521.48 $500.87 $436.46 $787.75 $646.04 $528.73 $502.1460 $810.03 $664.33 $543.72 $522.23 $455.07 $821.34 $673.59 $551.28 $523.5661 $838.68 $687.82 $562.95 $540.70 $471.17 $850.40 $697.41 $570.78 $542.0862 $857.48 $703.25 $575.57 $552.83 $481.73 $869.46 $713.05 $583.58 $554.2363 $881.06 $722.58 $591.40 $568.03 $494.98 $893.37 $732.66 $599.62 $569.4764 $895.38 $734.33 $601.01 $577.26 $503.03 $907.89 $744.57 $609.37 $578.73

65+ $895.38 $734.33 $601.01 $577.26 $503.03 $907.89 $744.57 $609.37 $578.73

Area 1: King County.Area 2: Island, Mason, Lewis, Kitsap, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties.Area 4: Spokane County.Area 5: Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties.

* Rates are charged to no more than the three oldest covered children under age 21 in a family.

1/1/2015 Individual Filing Group Health Cooperative

GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 11 - FINAL RATES


Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $196.54 $161.18 $131.92 $126.71 $110.41 $199.28 $163.43 $133.76 $127.0321 $309.51 $253.83 $207.75 $199.54 $173.88 $313.83 $257.37 $210.64 $200.0522 $309.51 $253.83 $207.75 $199.54 $173.88 $313.83 $257.37 $210.64 $200.0523 $309.51 $253.83 $207.75 $199.54 $173.88 $313.83 $257.37 $210.64 $200.0524 $309.51 $253.83 $207.75 $199.54 $173.88 $313.83 $257.37 $210.64 $200.0525 $310.74 $254.85 $208.58 $200.34 $174.57 $315.08 $258.40 $211.48 $200.8526 $316.93 $259.93 $212.74 $204.33 $178.05 $321.36 $263.55 $215.69 $204.8527 $324.36 $266.02 $217.72 $209.12 $182.23 $328.89 $269.73 $220.75 $209.6528 $336.43 $275.92 $225.82 $216.90 $189.01 $341.13 $279.76 $228.97 $217.4529 $346.34 $284.04 $232.47 $223.29 $194.57 $351.18 $288.00 $235.71 $223.8530 $351.29 $288.10 $235.80 $226.48 $197.35 $356.20 $292.12 $239.08 $227.0531 $358.72 $294.19 $240.78 $231.27 $201.53 $363.73 $298.30 $244.13 $231.8532 $366.15 $300.29 $245.77 $236.06 $205.70 $371.26 $304.47 $249.19 $236.6633 $370.79 $304.09 $248.88 $239.05 $208.31 $375.97 $308.33 $252.35 $239.6634 $375.74 $308.15 $252.21 $242.24 $211.09 $380.99 $312.45 $255.72 $242.8635 $378.22 $310.19 $253.87 $243.84 $212.48 $383.50 $314.51 $257.40 $244.4636 $380.69 $312.22 $255.53 $245.44 $213.87 $386.01 $316.57 $259.09 $246.0637 $383.17 $314.25 $257.19 $247.03 $215.26 $388.52 $318.63 $260.77 $247.6638 $385.64 $316.28 $258.86 $248.63 $216.65 $391.03 $320.69 $262.46 $249.2639 $390.60 $320.34 $262.18 $251.82 $219.44 $396.05 $324.80 $265.83 $252.4640 $395.55 $324.40 $265.50 $255.01 $222.22 $401.07 $328.92 $269.20 $255.6641 $402.98 $330.49 $270.49 $259.80 $226.39 $408.61 $335.10 $274.25 $260.4642 $410.10 $336.33 $275.27 $264.39 $230.39 $415.82 $341.02 $279.10 $265.0643 $420.00 $344.45 $281.92 $270.78 $235.95 $425.87 $349.26 $285.84 $271.4644 $432.38 $354.61 $290.23 $278.76 $242.91 $438.42 $359.55 $294.26 $279.4745 $446.93 $366.54 $299.99 $288.14 $251.08 $453.17 $371.65 $304.16 $288.8746 $464.26 $380.75 $311.62 $299.31 $260.82 $470.74 $386.06 $315.96 $300.0747 $483.76 $396.74 $324.71 $311.88 $271.77 $490.52 $402.27 $329.23 $312.6748 $506.04 $415.02 $339.67 $326.25 $284.29 $513.11 $420.81 $344.40 $327.0849 $528.02 $433.04 $354.42 $340.42 $296.64 $535.39 $439.08 $359.35 $341.2850 $552.78 $453.35 $371.04 $356.38 $310.55 $560.50 $459.67 $376.20 $357.2851 $577.23 $473.40 $387.45 $372.14 $324.28 $585.29 $480.00 $392.84 $373.0952 $604.16 $495.48 $405.53 $389.50 $339.41 $612.59 $502.39 $411.17 $390.4953 $631.39 $517.82 $423.81 $407.06 $354.71 $640.21 $525.04 $429.70 $408.1054 $660.80 $541.94 $443.55 $426.02 $371.23 $670.03 $549.49 $449.72 $427.1055 $690.20 $566.05 $463.28 $444.98 $387.75 $699.84 $573.94 $469.73 $446.1156 $722.08 $592.20 $484.68 $465.53 $405.66 $732.16 $600.45 $491.42 $466.7157 $754.27 $618.59 $506.29 $486.28 $423.74 $764.80 $627.22 $513.33 $487.5158 $788.62 $646.77 $529.35 $508.43 $443.04 $799.64 $655.79 $536.71 $509.7259 $805.64 $660.73 $540.77 $519.41 $452.61 $816.90 $669.94 $548.29 $520.7260 $840.00 $688.91 $563.83 $541.56 $471.91 $851.73 $698.51 $571.68 $542.9361 $869.71 $713.27 $583.78 $560.71 $488.60 $881.86 $723.22 $591.90 $562.1362 $889.21 $729.27 $596.87 $573.28 $499.56 $901.63 $739.43 $605.17 $574.7463 $913.66 $749.32 $613.28 $589.05 $513.29 $926.42 $759.77 $621.81 $590.5464 $928.52 $761.49 $623.25 $598.62 $521.64 $941.49 $772.12 $631.92 $600.14

65+ $928.52 $761.49 $623.25 $598.62 $521.64 $941.49 $772.12 $631.92 $600.14






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315


Plan Name: Core3 Gold -15 Core3 Silver -15 Core3 Bronze - 15 Core Bronze H.S.A. - Core Basics Plus -15 Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15 Core Bronze H.S.A. -15Plan ID: 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001Exchange Plan?: Yes Yes Yes Yes Yes No No No NoAge Band

0-20* $181.18 $148.59 $121.62 $116.81 $101.79 $183.72 $150.67 $123.31 $117.1121 $285.33 $234.01 $191.52 $183.96 $160.30 $289.32 $237.27 $194.19 $184.4222 $285.33 $234.01 $191.52 $183.96 $160.30 $289.32 $237.27 $194.19 $184.4223 $285.33 $234.01 $191.52 $183.96 $160.30 $289.32 $237.27 $194.19 $184.4224 $285.33 $234.01 $191.52 $183.96 $160.30 $289.32 $237.27 $194.19 $184.4225 $286.47 $234.94 $192.29 $184.69 $160.94 $290.47 $238.22 $194.96 $185.1626 $292.18 $239.62 $196.12 $188.37 $164.14 $296.26 $242.96 $198.85 $188.8527 $299.03 $245.24 $200.72 $192.78 $167.99 $303.20 $248.66 $203.51 $193.2728 $310.15 $254.37 $208.18 $199.96 $174.24 $314.49 $257.91 $211.08 $200.4729 $319.28 $261.85 $214.31 $205.85 $179.37 $323.74 $265.50 $217.29 $206.3730 $323.85 $265.60 $217.38 $208.79 $181.94 $328.37 $269.30 $220.40 $209.3231 $330.70 $271.21 $221.97 $213.20 $185.78 $335.32 $275.00 $225.06 $213.7432 $337.55 $276.83 $226.57 $217.62 $189.63 $342.26 $280.69 $229.72 $218.1733 $341.83 $280.34 $229.44 $220.38 $192.04 $346.60 $284.25 $232.64 $220.9434 $346.39 $284.08 $232.51 $223.32 $194.60 $351.23 $288.05 $235.74 $223.8935 $348.67 $285.96 $234.04 $224.79 $195.88 $353.54 $289.94 $237.30 $225.3636 $350.96 $287.83 $235.57 $226.26 $197.17 $355.86 $291.84 $238.85 $226.8437 $353.24 $289.70 $237.10 $227.74 $198.45 $358.17 $293.74 $240.40 $228.3138 $355.52 $291.57 $238.64 $229.21 $199.73 $360.49 $295.64 $241.96 $229.7939 $360.09 $295.32 $241.70 $232.15 $202.30 $365.12 $299.43 $245.06 $232.7440 $364.65 $299.06 $244.77 $235.09 $204.86 $369.75 $303.23 $248.17 $235.6941 $371.50 $304.68 $249.36 $239.51 $208.71 $376.69 $308.93 $252.83 $240.1242 $378.06 $310.06 $253.77 $243.74 $212.39 $383.34 $314.38 $257.30 $244.3643 $387.19 $317.55 $259.90 $249.63 $217.52 $392.60 $321.98 $263.51 $250.2644 $398.61 $326.91 $267.56 $256.99 $223.94 $404.17 $331.47 $271.28 $257.6445 $412.02 $337.91 $276.56 $265.63 $231.47 $417.77 $342.62 $280.41 $266.3046 $428.00 $351.01 $287.28 $275.93 $240.45 $433.97 $355.90 $291.28 $276.6347 $445.97 $365.75 $299.35 $287.52 $250.55 $452.20 $370.85 $303.51 $288.2548 $466.52 $382.60 $313.14 $300.77 $262.09 $473.03 $387.94 $317.49 $301.5349 $486.77 $399.22 $326.74 $313.83 $273.47 $493.57 $404.78 $331.28 $314.6250 $509.60 $417.94 $342.06 $328.54 $286.29 $516.72 $423.76 $346.82 $329.3851 $532.14 $436.42 $357.19 $343.08 $298.96 $539.57 $442.51 $362.16 $343.9552 $556.97 $456.78 $373.85 $359.08 $312.90 $564.75 $463.15 $379.05 $359.9953 $582.07 $477.37 $390.71 $375.27 $327.01 $590.21 $484.03 $396.14 $376.2254 $609.18 $499.61 $408.90 $392.74 $342.24 $617.69 $506.57 $414.59 $393.7455 $636.29 $521.84 $427.10 $410.22 $357.46 $645.18 $529.11 $433.04 $411.2656 $665.68 $545.94 $446.82 $429.17 $373.97 $674.97 $553.55 $453.04 $430.2657 $695.35 $570.28 $466.74 $448.30 $390.65 $705.06 $578.23 $473.23 $449.4458 $727.02 $596.25 $488.00 $468.72 $408.44 $737.18 $604.56 $494.79 $469.9159 $742.72 $609.12 $498.53 $478.84 $417.25 $753.09 $617.61 $505.47 $480.0560 $774.39 $635.10 $519.79 $499.25 $435.05 $785.20 $643.95 $527.02 $500.5261 $801.78 $657.56 $538.18 $516.91 $450.44 $812.98 $666.73 $545.66 $518.2262 $819.75 $672.30 $550.24 $528.50 $460.54 $831.21 $681.68 $557.90 $529.8463 $842.30 $690.79 $565.37 $543.04 $473.20 $854.06 $700.42 $573.24 $544.4164 $855.99 $702.02 $574.56 $551.87 $480.89 $867.95 $711.81 $582.56 $553.26

65+ $855.99 $702.02 $574.56 $551.87 $480.89 $867.95 $711.81 $582.56 $553.26






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $190.28 $156.06 $127.72 $122.68 $106.90 $192.94 $158.23 $129.50 $122.9921 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6822 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6823 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6824 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6825 $300.86 $246.74 $201.94 $193.96 $169.02 $305.06 $250.18 $204.75 $194.4626 $306.85 $251.65 $205.97 $197.83 $172.39 $311.13 $255.16 $208.83 $198.3327 $314.04 $257.55 $210.79 $202.46 $176.43 $318.43 $261.14 $213.73 $202.9828 $325.73 $267.14 $218.64 $210.00 $182.99 $330.28 $270.86 $221.68 $210.5329 $335.32 $275.00 $225.07 $216.18 $188.38 $340.00 $278.84 $228.20 $216.7330 $340.11 $278.93 $228.29 $219.27 $191.07 $344.86 $282.82 $231.47 $219.8331 $347.30 $284.83 $233.12 $223.91 $195.11 $352.15 $288.80 $236.36 $224.4832 $354.49 $290.73 $237.95 $228.55 $199.15 $359.45 $294.78 $241.26 $229.1233 $358.99 $294.42 $240.96 $231.44 $201.68 $364.00 $298.52 $244.32 $232.0334 $363.78 $298.35 $244.18 $234.53 $204.37 $368.86 $302.51 $247.58 $235.1335 $366.18 $300.31 $245.79 $236.08 $205.72 $371.30 $304.50 $249.21 $236.6836 $368.58 $302.28 $247.40 $237.63 $207.07 $373.73 $306.49 $250.84 $238.2337 $370.98 $304.25 $249.01 $239.17 $208.41 $376.16 $308.49 $252.47 $239.7838 $373.37 $306.21 $250.62 $240.72 $209.76 $378.59 $310.48 $254.10 $241.3339 $378.17 $310.14 $253.84 $243.81 $212.45 $383.45 $314.47 $257.37 $244.4340 $382.96 $314.08 $257.06 $246.90 $215.15 $388.31 $318.46 $260.63 $247.5241 $390.15 $319.98 $261.88 $251.54 $219.19 $395.60 $324.44 $265.53 $252.1742 $397.05 $325.63 $266.51 $255.98 $223.06 $402.59 $330.17 $270.22 $256.6343 $406.63 $333.49 $272.95 $262.16 $228.45 $412.31 $338.14 $276.74 $262.8344 $418.62 $343.32 $280.99 $269.89 $235.18 $424.47 $348.11 $284.90 $270.5745 $432.70 $354.87 $290.44 $278.97 $243.09 $438.75 $359.82 $294.48 $279.6846 $449.49 $368.63 $301.71 $289.79 $252.52 $455.76 $373.77 $305.90 $290.5247 $468.36 $384.12 $314.38 $301.96 $263.12 $474.91 $389.47 $318.75 $302.7248 $489.94 $401.81 $328.86 $315.87 $275.25 $496.78 $407.41 $333.44 $316.6749 $511.21 $419.26 $343.14 $329.58 $287.20 $518.36 $425.11 $347.92 $330.4250 $535.19 $438.92 $359.23 $345.04 $300.67 $542.66 $445.04 $364.23 $345.9151 $558.86 $458.34 $375.12 $360.30 $313.97 $566.67 $464.73 $380.34 $361.2252 $584.93 $479.72 $392.62 $377.11 $328.61 $593.10 $486.41 $398.08 $378.0753 $611.30 $501.34 $410.32 $394.11 $343.43 $619.84 $508.33 $416.03 $395.1154 $639.77 $524.69 $429.43 $412.46 $359.42 $648.70 $532.01 $435.40 $413.5155 $668.23 $548.04 $448.54 $430.82 $375.41 $677.57 $555.68 $454.78 $431.9156 $699.10 $573.35 $469.26 $450.72 $392.75 $708.86 $581.34 $475.78 $451.8657 $730.26 $598.91 $490.18 $470.81 $410.26 $740.46 $607.26 $496.99 $472.0058 $763.53 $626.19 $512.50 $492.25 $428.95 $774.19 $634.92 $519.63 $493.5059 $780.01 $639.70 $523.56 $502.88 $438.20 $790.90 $648.62 $530.85 $504.1560 $813.27 $666.98 $545.89 $524.32 $456.89 $824.63 $676.28 $553.48 $525.6561 $842.04 $690.58 $565.20 $542.87 $473.05 $853.80 $700.20 $573.06 $544.2462 $860.91 $706.06 $577.87 $555.04 $483.66 $872.94 $715.90 $585.91 $556.4563 $884.59 $725.47 $593.76 $570.30 $496.96 $896.94 $735.59 $602.02 $571.7564 $898.97 $737.27 $603.42 $579.57 $505.04 $911.52 $747.55 $611.81 $581.04

65+ $898.97 $737.27 $603.42 $579.57 $505.04 $911.52 $747.55 $611.81 $581.04





Tobacco User Status: Tobacco User Area: 1

Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $189.52 $155.43 $127.21 $122.19 $106.47 $192.17 $157.60 $128.98 $122.5021 $358.16 $293.73 $240.40 $230.91 $201.21 $363.16 $297.83 $243.75 $231.4922 $358.16 $293.73 $240.40 $230.91 $201.21 $363.16 $297.83 $243.75 $231.4923 $358.16 $293.73 $240.40 $230.91 $201.21 $363.16 $297.83 $243.75 $231.4924 $358.16 $293.73 $240.40 $230.91 $201.21 $363.16 $297.83 $243.75 $231.4925 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4226 $366.75 $300.78 $246.17 $236.45 $206.04 $371.87 $304.98 $249.60 $237.0527 $375.35 $307.83 $251.94 $241.99 $210.87 $380.59 $312.12 $255.45 $242.6028 $389.32 $319.29 $261.32 $250.99 $218.72 $394.75 $323.74 $264.95 $251.6329 $400.78 $328.69 $269.01 $258.38 $225.15 $406.37 $333.27 $272.75 $259.0430 $406.51 $333.39 $272.86 $262.08 $228.37 $412.18 $338.03 $276.65 $262.7431 $415.10 $340.44 $278.63 $267.62 $233.20 $420.90 $345.18 $282.50 $268.3032 $423.70 $347.49 $284.40 $273.16 $238.03 $429.62 $352.33 $288.35 $273.8533 $429.07 $351.89 $288.00 $276.63 $241.05 $435.06 $356.80 $292.01 $277.3334 $434.80 $356.59 $291.85 $280.32 $244.27 $440.87 $361.56 $295.91 $281.0335 $437.67 $358.94 $293.77 $282.17 $245.88 $443.78 $363.95 $297.86 $282.8836 $440.53 $361.29 $295.70 $284.01 $247.49 $446.68 $366.33 $299.81 $284.7337 $443.40 $363.64 $297.62 $285.86 $249.10 $449.59 $368.71 $301.76 $286.5938 $446.26 $365.99 $299.54 $287.71 $250.71 $452.50 $371.09 $303.71 $288.4439 $451.99 $370.69 $303.39 $291.40 $253.93 $458.31 $375.86 $307.61 $292.1440 $457.72 $375.39 $307.24 $295.10 $257.15 $464.12 $380.62 $311.51 $295.8541 $466.32 $382.44 $313.01 $300.64 $261.98 $472.83 $387.77 $317.36 $301.4042 $474.56 $389.20 $318.54 $305.95 $266.60 $481.18 $394.62 $322.97 $306.7343 $486.02 $398.60 $326.23 $313.34 $273.04 $492.81 $404.15 $330.77 $314.1344 $500.34 $410.34 $335.85 $322.58 $281.09 $507.33 $416.07 $340.52 $323.3945 $517.18 $424.15 $347.14 $333.43 $290.55 $524.40 $430.06 $351.97 $334.2746 $537.23 $440.60 $360.61 $346.36 $301.82 $544.74 $446.74 $365.62 $347.2447 $559.80 $459.10 $375.75 $360.91 $314.49 $567.62 $465.51 $380.98 $361.8248 $585.58 $480.25 $393.06 $377.53 $328.98 $593.76 $486.95 $398.53 $378.4949 $611.01 $501.11 $410.13 $393.93 $343.26 $619.55 $508.09 $415.84 $394.9250 $639.67 $524.61 $429.36 $412.40 $359.36 $648.60 $531.92 $435.34 $413.4451 $667.96 $547.81 $448.35 $430.64 $375.26 $677.29 $555.45 $454.59 $431.7352 $699.12 $573.37 $469.27 $450.73 $392.76 $708.89 $581.36 $475.80 $451.8753 $730.64 $599.22 $490.43 $471.05 $410.47 $740.84 $607.57 $497.25 $472.2454 $764.66 $627.12 $513.26 $492.98 $429.58 $775.34 $635.86 $520.40 $494.2355 $798.69 $655.02 $536.10 $514.92 $448.70 $809.84 $664.16 $543.56 $516.2356 $835.58 $685.28 $560.86 $538.70 $469.42 $847.25 $694.83 $568.67 $540.0757 $872.82 $715.83 $585.87 $562.72 $490.35 $885.02 $725.81 $594.02 $564.1458 $912.58 $748.43 $612.55 $588.35 $512.68 $925.33 $758.87 $621.07 $589.8459 $932.28 $764.59 $625.77 $601.05 $523.75 $945.30 $775.25 $634.48 $602.5760 $972.03 $797.19 $652.46 $626.68 $546.09 $985.61 $808.31 $661.53 $628.2761 $1,006.42 $825.39 $675.54 $648.85 $565.40 $1,020.48 $836.90 $684.93 $650.4962 $1,028.98 $843.89 $690.68 $663.39 $578.08 $1,043.35 $855.66 $700.29 $665.0763 $1,057.28 $867.10 $709.68 $681.63 $593.97 $1,072.04 $879.19 $719.55 $683.3664 $1,074.47 $881.19 $721.20 $692.72 $603.63 $1,089.48 $893.48 $731.25 $694.47

65+ $1,074.47 $881.19 $721.20 $692.72 $603.63 $1,089.48 $893.48 $731.25 $694.47






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $196.54 $161.18 $131.92 $126.71 $110.41 $199.28 $163.43 $133.76 $127.0321 $371.41 $304.60 $249.30 $239.45 $208.66 $376.60 $308.85 $252.77 $240.0622 $371.41 $304.60 $249.30 $239.45 $208.66 $376.60 $308.85 $252.77 $240.0623 $371.41 $304.60 $249.30 $239.45 $208.66 $376.60 $308.85 $252.77 $240.0624 $371.41 $304.60 $249.30 $239.45 $208.66 $376.60 $308.85 $252.77 $240.0625 $372.89 $305.82 $250.30 $240.41 $209.49 $378.10 $310.08 $253.78 $241.0226 $380.32 $311.91 $255.28 $245.20 $213.66 $385.63 $316.26 $258.83 $245.8227 $389.23 $319.22 $261.27 $250.94 $218.67 $394.67 $323.67 $264.90 $251.5828 $403.72 $331.10 $270.99 $260.28 $226.81 $409.36 $335.72 $274.76 $260.9429 $415.60 $340.85 $278.97 $267.94 $233.49 $421.41 $345.60 $282.85 $268.6230 $421.55 $345.72 $282.96 $271.78 $236.82 $427.44 $350.54 $286.89 $272.4631 $430.46 $353.03 $288.94 $277.52 $241.83 $436.47 $357.95 $292.96 $278.2332 $439.37 $360.34 $294.92 $283.27 $246.84 $445.51 $365.37 $299.02 $283.9933 $444.95 $364.91 $298.66 $286.86 $249.97 $451.16 $370.00 $302.82 $287.5934 $450.89 $369.79 $302.65 $290.69 $253.31 $457.19 $374.94 $306.86 $291.4335 $453.86 $372.22 $304.64 $292.61 $254.98 $460.20 $377.41 $308.88 $293.3536 $456.83 $374.66 $306.64 $294.52 $256.65 $463.21 $379.88 $310.90 $295.2737 $459.80 $377.10 $308.63 $296.44 $258.32 $466.22 $382.35 $312.93 $297.1938 $462.77 $379.53 $310.63 $298.35 $259.98 $469.24 $384.82 $314.95 $299.1139 $468.72 $384.41 $314.62 $302.19 $263.32 $475.26 $389.77 $318.99 $302.9540 $474.66 $389.28 $318.61 $306.02 $266.66 $481.29 $394.71 $323.04 $306.7941 $483.57 $396.59 $324.59 $311.76 $271.67 $490.33 $402.12 $329.10 $312.5542 $492.11 $403.60 $330.32 $317.27 $276.47 $498.99 $409.22 $334.92 $318.0743 $504.00 $413.34 $338.30 $324.93 $283.15 $511.04 $419.11 $343.01 $325.7644 $518.86 $425.53 $348.27 $334.51 $291.49 $526.10 $431.46 $353.12 $335.3645 $536.31 $439.84 $359.99 $345.77 $301.30 $543.80 $445.98 $365.00 $346.6446 $557.11 $456.90 $373.95 $359.17 $312.98 $564.89 $463.27 $379.15 $360.0847 $580.51 $476.09 $389.66 $374.26 $326.13 $588.62 $482.73 $395.08 $375.2148 $607.25 $498.02 $407.61 $391.50 $341.15 $615.73 $504.97 $413.27 $392.4949 $633.62 $519.65 $425.31 $408.50 $355.97 $642.47 $526.89 $431.22 $409.5450 $663.33 $544.02 $445.25 $427.66 $372.66 $672.60 $551.60 $451.44 $428.7451 $692.67 $568.08 $464.94 $446.57 $389.14 $702.35 $576.00 $471.41 $447.7152 $724.99 $594.58 $486.63 $467.41 $407.29 $735.11 $602.87 $493.40 $468.5953 $757.67 $621.39 $508.57 $488.48 $425.66 $768.25 $630.05 $515.65 $489.7254 $792.95 $650.32 $532.26 $511.22 $445.48 $804.03 $659.39 $539.66 $512.5255 $828.24 $679.26 $555.94 $533.97 $465.30 $839.81 $688.73 $563.67 $535.3356 $866.49 $710.63 $581.62 $558.64 $486.79 $878.60 $720.54 $589.71 $560.0557 $905.12 $742.31 $607.54 $583.54 $508.49 $917.76 $752.66 $615.99 $585.0258 $946.35 $776.12 $635.22 $610.12 $531.65 $959.56 $786.94 $644.05 $611.6659 $966.77 $792.88 $648.93 $623.29 $543.13 $980.28 $803.93 $657.95 $624.8760 $1,008.00 $826.69 $676.60 $649.87 $566.29 $1,022.08 $838.21 $686.01 $651.5161 $1,043.65 $855.93 $700.53 $672.85 $586.32 $1,058.23 $867.86 $710.28 $674.5662 $1,067.05 $875.12 $716.24 $687.94 $599.47 $1,081.96 $887.32 $726.20 $689.6863 $1,096.39 $899.18 $735.93 $706.86 $615.95 $1,111.71 $911.72 $746.17 $708.6564 $1,114.22 $913.80 $747.90 $718.35 $625.97 $1,129.79 $926.54 $758.30 $720.17

65+ $1,114.22 $913.80 $747.90 $718.35 $625.97 $1,129.79 $926.54 $758.30 $720.17






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315



0-20* $181.18 $148.59 $121.62 $116.81 $101.79 $183.72 $150.67 $123.31 $117.1121 $342.40 $280.81 $229.83 $220.75 $192.36 $347.18 $284.72 $233.02 $221.3122 $342.40 $280.81 $229.83 $220.75 $192.36 $347.18 $284.72 $233.02 $221.3123 $342.40 $280.81 $229.83 $220.75 $192.36 $347.18 $284.72 $233.02 $221.3124 $342.40 $280.81 $229.83 $220.75 $192.36 $347.18 $284.72 $233.02 $221.3125 $343.77 $281.93 $230.75 $221.63 $193.13 $348.57 $285.86 $233.96 $222.1926 $350.61 $287.55 $235.34 $226.04 $196.97 $355.51 $291.56 $238.62 $226.6227 $358.83 $294.29 $240.86 $231.34 $201.59 $363.84 $298.39 $244.21 $231.9328 $372.19 $305.24 $249.82 $239.95 $209.09 $377.38 $309.49 $253.30 $240.5629 $383.14 $314.22 $257.18 $247.01 $215.25 $388.49 $318.61 $260.75 $247.6430 $388.62 $318.72 $260.85 $250.55 $218.33 $394.05 $323.16 $264.48 $251.1831 $396.84 $325.46 $266.37 $255.84 $222.94 $402.38 $329.99 $270.07 $256.4932 $405.06 $332.20 $271.89 $261.14 $227.56 $410.71 $336.83 $275.67 $261.8033 $410.19 $336.41 $275.33 $264.45 $230.44 $415.92 $341.10 $279.16 $265.1234 $415.67 $340.90 $279.01 $267.99 $233.52 $421.48 $345.65 $282.89 $268.6735 $418.41 $343.15 $280.85 $269.75 $235.06 $424.25 $347.93 $284.76 $270.4436 $421.15 $345.39 $282.69 $271.52 $236.60 $427.03 $350.21 $286.62 $272.2137 $423.89 $347.64 $284.53 $273.28 $238.14 $429.81 $352.49 $288.48 $273.9838 $426.63 $349.89 $286.36 $275.05 $239.68 $432.59 $354.77 $290.35 $275.7539 $432.10 $354.38 $290.04 $278.58 $242.75 $438.14 $359.32 $294.08 $279.2940 $437.58 $358.87 $293.72 $282.11 $245.83 $443.70 $363.88 $297.80 $282.8341 $445.80 $365.61 $299.23 $287.41 $250.45 $452.03 $370.71 $303.40 $288.1442 $453.68 $372.07 $304.52 $292.49 $254.87 $460.01 $377.26 $308.76 $293.2343 $464.63 $381.06 $311.88 $299.55 $261.03 $471.12 $386.37 $316.21 $300.3144 $478.33 $392.29 $321.07 $308.38 $268.72 $485.01 $397.76 $325.53 $309.1645 $494.42 $405.49 $331.87 $318.76 $277.76 $501.33 $411.14 $336.49 $319.5746 $513.59 $421.21 $344.74 $331.12 $288.54 $520.77 $427.09 $349.54 $331.9647 $535.17 $438.90 $359.22 $345.03 $300.65 $542.64 $445.02 $364.22 $345.9048 $559.82 $459.12 $375.77 $360.92 $314.50 $567.64 $465.52 $380.99 $361.8349 $584.13 $479.06 $392.08 $376.59 $328.16 $592.29 $485.74 $397.54 $377.5550 $611.52 $501.52 $410.47 $394.25 $343.55 $620.06 $508.52 $416.18 $395.2551 $638.57 $523.71 $428.63 $411.69 $358.75 $647.49 $531.01 $434.59 $412.7452 $668.36 $548.14 $448.62 $430.90 $375.48 $677.69 $555.78 $454.86 $431.9953 $698.49 $572.85 $468.85 $450.32 $392.41 $708.25 $580.84 $475.37 $451.4654 $731.02 $599.53 $490.68 $471.29 $410.68 $741.23 $607.89 $497.51 $472.4955 $763.54 $626.20 $512.51 $492.26 $428.96 $774.21 $634.93 $519.64 $493.5156 $798.81 $655.13 $536.19 $515.00 $448.77 $809.97 $664.26 $543.64 $516.3157 $834.42 $684.33 $560.09 $537.96 $468.77 $846.08 $693.87 $567.88 $539.3258 $872.43 $715.50 $585.60 $562.46 $490.13 $884.61 $725.48 $593.74 $563.8959 $891.26 $730.94 $598.24 $574.60 $500.71 $903.71 $741.14 $606.56 $576.0660 $929.26 $762.11 $623.75 $599.11 $522.06 $942.24 $772.74 $632.43 $600.6261 $962.13 $789.07 $645.81 $620.30 $540.52 $975.57 $800.07 $654.80 $621.8762 $983.71 $806.76 $660.29 $634.20 $552.64 $997.45 $818.01 $669.48 $635.8163 $1,010.75 $828.95 $678.45 $651.64 $567.84 $1,024.87 $840.50 $687.89 $653.2964 $1,027.19 $842.43 $689.48 $662.24 $577.07 $1,041.54 $854.17 $699.07 $663.92

65+ $1,027.19 $842.43 $689.48 $662.24 $577.07 $1,041.54 $854.17 $699.07 $663.92






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $190.28 $156.06 $127.72 $122.68 $106.90 $192.94 $158.23 $129.50 $122.9921 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4222 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4223 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4224 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4225 $361.03 $296.09 $242.33 $232.76 $202.82 $366.07 $300.22 $245.70 $233.3526 $368.22 $301.99 $247.16 $237.39 $206.86 $373.36 $306.20 $250.60 $238.0027 $376.85 $309.06 $252.95 $242.96 $211.71 $382.11 $313.37 $256.47 $243.5728 $390.87 $320.56 $262.37 $252.00 $219.59 $396.33 $325.03 $266.01 $252.6429 $402.38 $330.00 $270.09 $259.42 $226.06 $408.00 $334.60 $273.85 $260.0830 $408.13 $334.72 $273.95 $263.13 $229.29 $413.83 $339.39 $277.76 $263.7931 $416.76 $341.80 $279.74 $268.69 $234.14 $422.58 $346.56 $283.63 $269.3732 $425.39 $348.88 $285.54 $274.25 $238.98 $431.33 $353.74 $289.51 $274.9533 $430.79 $353.30 $289.16 $277.73 $242.01 $436.80 $358.23 $293.18 $278.4434 $436.54 $358.02 $293.02 $281.44 $245.25 $442.64 $363.01 $297.09 $282.1535 $439.42 $360.38 $294.95 $283.30 $246.86 $445.55 $365.40 $299.05 $284.0136 $442.29 $362.74 $296.88 $285.15 $248.48 $448.47 $367.79 $301.01 $285.8737 $445.17 $365.10 $298.81 $287.01 $250.09 $451.39 $370.19 $302.97 $287.7338 $448.05 $367.46 $300.74 $288.86 $251.71 $454.31 $372.58 $304.93 $289.5939 $453.80 $372.17 $304.60 $292.57 $254.94 $460.14 $377.36 $308.84 $293.3140 $459.55 $376.89 $308.47 $296.28 $258.18 $465.97 $382.15 $312.76 $297.0341 $468.18 $383.97 $314.26 $301.84 $263.02 $474.72 $389.32 $318.63 $302.6142 $476.45 $390.75 $319.81 $307.17 $267.67 $483.11 $396.20 $324.26 $307.9543 $487.96 $400.19 $327.53 $314.59 $274.13 $494.78 $405.77 $332.09 $315.3944 $502.34 $411.99 $337.19 $323.87 $282.22 $509.36 $417.73 $341.88 $324.6945 $519.25 $425.85 $348.53 $334.76 $291.71 $526.50 $431.78 $353.38 $335.6146 $539.38 $442.36 $362.05 $347.74 $303.02 $546.92 $448.53 $367.09 $348.6347 $562.04 $460.94 $377.26 $362.35 $315.75 $569.89 $467.37 $382.50 $363.2748 $587.93 $482.17 $394.63 $379.04 $330.29 $596.14 $488.90 $400.12 $380.0049 $613.46 $503.11 $411.77 $395.50 $344.64 $622.03 $510.13 $417.50 $396.5050 $642.22 $526.71 $431.08 $414.05 $360.80 $651.20 $534.05 $437.08 $415.1051 $670.63 $550.00 $450.15 $432.36 $376.76 $680.00 $557.67 $456.41 $433.4652 $701.92 $575.66 $471.15 $452.53 $394.33 $711.72 $583.69 $477.70 $453.6853 $733.56 $601.61 $492.39 $472.93 $412.11 $743.81 $610.00 $499.24 $474.1354 $767.72 $629.63 $515.32 $494.96 $431.30 $778.44 $638.41 $522.49 $496.2155 $801.88 $657.64 $538.25 $516.98 $450.49 $813.08 $666.81 $545.73 $518.2956 $838.92 $688.02 $563.11 $540.86 $471.30 $850.64 $697.61 $570.94 $542.2357 $876.32 $718.69 $588.21 $564.97 $492.31 $888.56 $728.71 $596.39 $566.4058 $916.23 $751.43 $615.00 $590.70 $514.73 $929.03 $761.90 $623.56 $592.2059 $936.01 $767.65 $628.28 $603.45 $525.85 $949.08 $778.35 $637.02 $604.9860 $975.92 $800.38 $655.07 $629.19 $548.27 $989.55 $811.54 $664.18 $630.7861 $1,010.44 $828.69 $678.24 $651.44 $567.66 $1,024.56 $840.24 $687.67 $653.0962 $1,033.10 $847.27 $693.45 $666.05 $580.39 $1,047.53 $859.08 $703.09 $667.7463 $1,061.50 $870.57 $712.51 $684.36 $596.35 $1,076.33 $882.71 $722.42 $686.1064 $1,078.76 $884.72 $724.10 $695.49 $606.05 $1,093.83 $897.06 $734.17 $697.25

65+ $1,078.76 $884.72 $724.10 $695.49 $606.05 $1,093.83 $897.06 $734.17 $697.25





Supporting Document Schedules Satisfied - Item: Actuarial Memorandum and CertificationsComments:Attachment(s): Part III Rate Filing Documentation and Actuarial Memorandum.pdfItem Status:Status Date:

Satisfied - Item: Consumer Disclosure Form DescriptionsComments:Attachment(s): Part II Written Explanation of the Rate Increase.pdfItem Status:Status Date:

Satisfied - Item: Unified Rate Review TemplateComments:

Attachment(s): Part I Unified Rate Review Data Template.pdfPart I Unified Rate Review Data Template Duplicate.xlsm

Item Status:Status Date:

Satisfied - Item: Rate Filing DocumentsComments: Attached are the rate filing documents.

Attachment(s): WAC 284-43-945.pdf1-2015 GHC Individual Rate Filing.pdf

Item Status:Status Date:

Satisfied - Item: Duplicate FilesComments: Attached is the duplicate file.Attachment(s): 1-2015 GHC Individual Rate Exhibits Duplicate.xlsxItem Status:Status Date:







Actuarial Memorandum

2015 Individual Rate Filing Page 1 Group Health Cooperative

Table of Contents Page Number 1. General Information 2 2. Proposed Rate Increase 2 3. Experience Period Premium and Claims 2 4. Benefit Categories 4 5. Projection Factors 4 6. Credibility Manual Rate Development 9 7. Credibility of Experience 9 8. Paid to Allowed Ratio 10 9. Risk Adjustment and Reinsurance 11 10. Non-Benefit Expenses and Profit & Risk 12 11. Projected Loss Ratio 15 12. Single Risk Pool 15 13. Index Rate 15 14. Market Adjusted Index Rate 17 15. Plan Adjusted Index Rate 18 16. Calibration 21 17. Consumer Adjusted Premium Rates 23 18. AV Metal Values 25 19. AV Pricing Values 26 20. Membership Projections 26 21. Terminated Products 26 22. Plan Type 27 23. Warning Alerts and Template Issues 27 24. Effective Rate Review Information 27 25. Reliance 28 26. Required Items per Actuarial Standards of Practice (ASOP) 41 29 27. Actuarial Certification 31



1. General Information a. Company Information • Company Legal Name: Group Health Cooperative • State: Washington • HIOS Issuer ID: 80473 • Market: Individual • Effective Date: January 1, 2015 b. Company Contact Information • Primary Contact Name: Melinda Hews • Primary Contact Telephone Number: (206) 448-5547 • Primary Contact email address: [email protected] 2. Proposed Rate Increase There is no proposed rate increase because all plans are new in 2015. 3. Experience Period Premium, Claims and Capital and Surplus

a. Dates of Service for the Experience Period Used to Develop Rates: January 1, 2013 through December 31, 2013

b. Paid Through date: February 28th, 2014

c. Premiums (net of MLR Rebate) in Experience Period:

Premiums were taken from the Group Health membership and billing systems and are adjusted for retroactive membership activity. Premiums prior to MLR rebates for calendar 2013 were: Earned premium prior to MLR Rebates For 2013

MLR Rebate expected For 2013

$69,744,636 $0

d. We expect the MLR rebate for 2013 will result in no refunds. This is based on the preliminary 2013 MLR information in the Supplemental Health Care forms submitted to the WA state Office of the Insurance Commissioner. Therefore the premiums after MLR rebates will equal Premiums prior to MLR rebates.

e. Allowed and Incurred Claims during the Experience Period:

i. All claims are processed through Group Health’s claims systems except pharmacy claims which are processed through MedImpact’s (a TPA) claims system. In the following information, paid claims means paid dollar claims



net of cost shares. Please see table below for allowed amounts and paid amounts broken out by GH claims system and non-GH claims systems:

Incurred 2013, Paid Through 2-2014 Non-GH Claims System

Incurred 2013, Paid Through 2-2014 GH Claims System

Incurred 2013, Paid Through 2-2014 Total

Total IBNP (Incurred But Not Paid) Total 2013 Incurred

Allowed Amounts $9,122,266 $71,846,986 $80,969,252 $3,162,680 $84,131,932Paid Amounts $7,024,007 $53,504,572 $60,528,579 $2,364,262 $62,892,841

ii. Method used for determining Allowed amounts:

The allowed amounts and paid amounts in Worksheet 1, section 1 were taken directly from the claims system files. The allowed amounts are not derived by adding cost shares to paid amounts.

iii. Incurred but Not Paid (IBNP) Claims Estimate: We used the development approach to develop the IBNP claim liability estimate. Our methodology has provided for both reported and unreported claims. In general, our methodology develops claim completion factors from recent historical experience using a completion ratio method for all but the most recent month where claims trend for the PMPM claims is primarily used. We based our best-estimate liability on: historical completion ratios, historical levels of PMPM incurred costs, trends in incurred costs, and known seasonal variations.

iv. The allowed amounts used completion factors based on the corporate total commercial pool incurred factors that are on a paid claim basis (i.e. net of cost shares). These completion factors are also filed and used in the development of the Large Group rates. The provider networks are the same for Large Group, and Small Group, and Individual Lines of Businesses (LOBs), therefore the factors should be a good representation of each LOB. The paid amount incurred claims were developed using statutory and data warehouse claim information.

v. Allowed vs. Paid Amounts: We applied the same completion factors in the development of the paid amount IBNP as the allowed amount IBNP.

vi. Additionally, the development of the claims expense estimates were reviewed for reasonableness by credentialed actuaries. With two months of run-out, the remaining



estimate for unpaid claims is quite small, relative to the total. These estimates for claims IBNP are calculated as best estimate, prior to the addition of margin.

vii. We added $1.5 million allowed to IBNP for four catastrophic claims (a set of premature quadruplets) incurred in 2013. The amount was estimated from a claim received but not paid for one of the quadruplets.

viii. No catastrophic claims were removed, nor any pooling charge applied.

ix. Prescription drug claims are net after rebates. Prescription drug rebates were $78,079 for 2013.

4. Benefit Categories The methodology used to assign claim experience is as follows: We used Milliman’s Health Cost Guidelines (HCG) Grouper, in order to categorize the historical claims into the benefit categories in Worksheet 1, Section II. The HCG Grouper uses a combination of HCPCS Codes, Revenue Codes, DRGs, Specialty Codes, Diagnosis Codes, and other indicators in order to categorize claim-level detail into benefit categories. These benefit categories are consistent with the categories used in Milliman’s Health Cost Guidelines. Milliman updates the HCG Grouper code sets and reporting workbooks at least once a year to incorporate new HCPCS, revenue codes, specialty codes, etc., so the classification methodology remains current. A description of the benefit categories follows. The Inpatient Hospital category is based on services incurred in an inpatient facility. The Outpatient Hospital category includes outpatient facility services. The Professional services category includes primary care physician, specialty care physician, chiropractic, physical therapy, vision exams, and other professional services. The Other Medical category includes lab and radiology, durable medical equipment, vision hardware, home health, and other services. The utilization for Other Medical services sums the counts of procedures or visits, as warranted. The Capitation category includes services from providers where we have capitation arrangements. The Prescription Drugs category consists of outpatient drugs obtained through a prescription by a physician. 5. Projection Factors

a. Changes in the Morbidity of the Population Insured To estimate the change in morbidity in the individual market from 2013 to 2015, in and out of the exchange we relied on the March 2013 Report sponsored by the Society of Actuaries: Cost of the Future Newly Insured under the Affordable Care Act (ACA). This report provided estimates of projected 2014 costs for the various categories of groups covered by health



insurance, under a status quo scenario and under different scenarios for the impact of the ACA. The projections were created using a model developed by the Lewin Group. The model reflected members’ coverage prior to 2014, and projected what type of coverage members would have in 2014. The model assumed that the individual mandate penalties and employer decisions (whether to offer coverage or pay penalties) were fully implemented. The authors produced results for 2 baseline scenarios and under alternate assumption scenarios, separately for each state. We selected the baseline scenario. The assumption of fully phased in penalties and employer decisions corresponds better to the 2015 market which has had time to react to 2014 market changes. The final morbidity factor is 1.1367. Our estimates of 2015 morbidity change over 2013 assume that GHC’s relative risk to the market does not change from 2013 to 2015. We assume that our morbidity change will follow the overall pool morbidity change in the market. Results from the Wakely Risk Adjustment Reporting project suggest that the risk mix of GHC is very close to the market average controlling for plan mix. Please see Exhibit 17 Population Morbidity in the WA state rate filing for more detail on the population morbidity adjustment. We do not anticipate any significant effect of pent-up demand due to the fact that individuals with significant unmet health needs are more likely to have purchased and utilized benefits in 2014 than to have waited until 2015. Therefore the pent-up demand is set to 1.0.

b. Changes in Benefits from 2013 Coverage (in “Other” adjustments in

Worksheet 1) The GHC individual plans have the following benefit changes/adjustments from plans in effect in 2013:

• Adult Optical Hardware (Non-Essential Health Benefit) coverage was removed from all plans. The factor to apply the “Other Medical” URRT benefit category was developed by dividing the adult optical hardware allowed claims by the “Other Medical” URRT total allowed claims.

• Pediatric Optical Hardware (Essential Health Benefit) coverage was added to all plans. The pediatric allowed claims pmpm for plans with the optical hardware benefit during the experience period were applied to all pediatric members to determine the “Other” adjustment for these changes.

• Adult Vision Exam (non-EHB) coverage was added to all plans. The adult vision exam allowed claims pmpm for plans with the vision exam benefit during the experience period were applied to all adult members to determine the “Other” adjustment for these changes.

• Pediatric Vision Exam (Essential Health Benefit) coverage was also added to all plans. The pediatric allowed claims pmpm for plans with the vision



exam benefit during the experience period were applied to all pediatric members to determine the “Other” adjustment for these changes..

• Embedded Pediatric Dental (Essential Health Benefit) coverage was

added to all Non-Exchange plans. The negotiated pmpms with the dental provider were weighted by area and adjusted up for their anticipated actuarial value to arrive at the allowed pediatric dental pmpms that were used to calculate the “Other” adjustment.

• The 2013 experience data is a mix of plans that cover drugs and maternity (comprehensive plans) and plans that do not cover drugs or maternity (catastrophic plans). Consequently, adjustments are needed to reflect that drugs and maternity are covered for all members. The maternity adjustment started with comprehensive plan allowed claims pmpm experience and adjusted it for the difference due to female demographics between comprehensive and catastrophic plans. Also, the calculated additional maternity claims were multiplied by 0.25 (75% reduction) in order to reflect our expectation that catastrophic plan members are less likely to use maternity benefits. Similarly, the drug adjustment started with comprehensive plan allowed claims pmpm experience and adjusted it for the difference due to age demographics between comprehensive and catastrophic plans using the ACA age factors. Also, a factor of 0.36 was applied to reflect our expectation that catastrophic plan members are less likely to use drug benefits.

• ABA (Applied Behavior Analysis for autism) was added to all plans. Zero cost impact was assigned.

• A Mental Health Residential Treatment Facility benefit was added to all plans. There is an assumed negligible cost increase so zero price impact was assigned.

• A Cardiac Rehabilitation Benefit was added to all plans. There is an assumed negligible cost increase so zero price impact was assigned.

• Orthotic Coverage was added to all plans. There is an assumed negligible cost increase so zero price impact was assigned. The following plan benefit limits have also changed from plans that were effect in 2013. There is an assumed negligible cost increase so zero price impact was assigned for all these limit changes.

• Home Health coverage changed from unlimited visits to a limit of 130 visits per year.

• Acupuncture for chemical dependency coverage changed from a limit of 8 visits per year to unlimited visits.



• Physical Therapy/Occupational Therapy/Speech Therapy coverage changed from a limit of 60 visits per year to a limit of 25 visits per year.

Please see Exhibit 7 Benefit Adjustments in the WA state rate filing for the detail behind all the benefit adjustments and reconciliation to the URRT “Other” adjustment factors.

2013 Allowed Claims Adjustment PMPM

Adult Vision Exam (Non EHB)(Add Benefit To All-Add'l Claims) +$1.02Adult Optical Hardware (Non EHB) (Remove Benefit) -$1.30Pediatric Vision Exam (EHB) (Add Benefit To All-Add'l Claims) +$0.13Pediatric Optical Hardware (EHB) (Add Benefit To All-Add'l Claims) +$0.06

Pediatric Dental (Add Benefit to All) +$9.44Maternity (Add Benefit To All-Add'l Claims) +$6.27Prescription Drug Including Non-Preferred Brand Drugs (Add Benefit To All-Add'l Claims) +$27.48

c. Changes in Demographics (in “Other” adjustments in Worksheet 1)

An adjustment for the change in demographics as reflected in 2013 member months to the demographics as of March 2014 was calculated and applied to all benefit categories in the URRT. The factor was calculated by first applying the ACA age factors, Group Health area factors and the Group Health tobacco use factor to each member in March 2014 and then dividing by the March 2014 member count to derive the member weighted average age/area/tobacco use factor of 1.746. This process was repeated for 2013 member months to derive the member weighted average age/area/tobacco use factor of 1.635. The demographic adjustment factor is then calculated as 1.746/1.635 = 1.068. The March 2014 demographics were then used to calibrate the plan adjusted index rates to derive the final consumer adjusted rates.

d. Other Adjustments (Adjustments other than benefits and demographics reflected in “Other” adjustments in Worksheet 1) There were no such adjustments in the rating.



e. Trend Factors (Cost and Utilization) Trend was developed using Group Health total commercial (Individual, Small and Large Group) experience. To ensure a stable population base, we chose to analyze the increased claim costs and utilization using the experience of only those members who were continuously insured for 36 months 2011-2013. A 12 month average of the last 12 month rolling averages was used as the starting point for derivation of the final pricing trends. We removed the effect of exactly one year of aging. Raw trends were calculated by medical service categories: Inpatient Hospital, Outpatient Hospital, Professional Services, Other Medical Services, Capitation and Prescription Drug. Units of service were then counted by each service category. The final trends used in pricing uses a combined average trend for Inpatient Hospital, Outpatient Hospital, Professional Services, and Other Medical Services. The expected Capitation trend is 0%. The Prescription Drug final trend used in pricing was the 6 month average of historical current rolling twelve month averages trend. Hepatitis C costs are expected to rise significantly in 2014 over 2013 due to the introduction of Sovaldi, which is a new drug treatment option with average total costs per patient over $120,000. Based on the current treatment capacity and Hepatitis C patient registry our Pharmacy department estimates an additional cost to the enterprise of $45M for 2014 and $94M in 2015. Full application of this cost would increase trend by 1.35% in 2014. We estimated that offsetting costs such as lower co-morbidity costs, new drugs approved with lower costs lower the impact to trend to 1.1%. The prescription drug and total medical trends are then separated into the following components: Utilization Developed using the simple average of the historical current 6 months rolling average of 12 month utilization trends. Cost Per Service Calculated by taking the total trend and removing the utilization trend. For 2015 we added an additional 1% of trend to account for our observation that in the 2nd Half of 2012 and the 1st half of 2013 trend dropped significantly and then in the 2nd half of 2013 began to rise again significantly. We looked for forward looking models that would explain the drop as well as the recent rise. We are using a 2013 paper from the Office of the Actuary at CMS: PROJECTIONS OF NATIONAL HEALTH EXPENDITURES: METHODOLOGY AND MODEL SPECIFICATION. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ProjectionsMethodology2012.pdf




Reports/NationalHealthExpendData/Downloads/ProjectionsMethodology2012.pdf Looking at this paper, the trend change appears to correlate well to Group Health cost trend changes. In Chart 2, Page 11, the change in trend from 2014 to 2015 is about 1%. In addition to this paper, in the development of the 2014 trend listed above, the starting point is a 12 month average of the last 12 month rolling averages. We note the trend is increasing during this period. This further supports the fact that trends are increasing. We are using a dental third party administrator to administer the pediatric dental benefit. There have not been any significant changes to our medical network. No additional changes were made to the adjusted historical utilization or cost per service trend since there are no specific Group Health business plans in place that are projected to affect utilization trends in the future. Please see Exhibit 3 Historical Trend and Exhibit 4 Final Pricing Trend in the WA state rate filing for more detail behind the trend calculation.

6. Credibility Manual Rate Development Group Health deemed its experience to be fully credible and thus did not merge any manual rates into its projected claim experience. Group Health is using the total commercial population to determine trend. Group Health believes the trend calculation requires a much larger data sample for credibility than the estimate to establish base rates. 7. Credibility of Experience The experience pool was large enough to be 100% credible in our judgment. Therefore we didn’t have a manual rate and associated credibility factors.





8. Paid to Allowed Ratio See the table below for support that the paid to allowed average factor for 2015 is appropriate and consistent with membership projections by plan for 2015. The “Benefit Relativity Factor” noted below is the adjusted metal AV used to determine the average rate pmpm in Worksheet 2 for each plan. Its derivation is shown in Section 15(a).

1 Product:

Group Health Cooperative

Individual and family Core3

Bronze Exchange

Group Health Cooperative I&F

Core H.S.A. Exchange


Individual and Family

Catastrophic 2 Product ID: 80473WA079 80473WA078 80473WA0813 Metal: Gold Silver Bronze Bronze Catastrophic4 AV Metal Value: 0.812 0.711 0.619 0.602 0.598

5Benefit Relativity Factor: 0.867 0.710 0.580 0.557 0.484

6 Plan Type: HMO HMO HMO HMO HMO

7Plan Name:

Core3 Gold -15 Core3 Silver -15 Core3 Bronze - 15Core Bronze

H.S.A. -15Core Basics Plus -

158 Plan ID : 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA08100019 Exchange Plan? Yes Yes Yes Yes Yes

10Projected 2015 Member Months 13,440 118,152 28,560 27,840 636

1 Product:


Individual and Family Core3 Bronze Direct


Individual and Family Core H.S.A. Direct

2 Product ID: 80473WA083 80473WA0823 Metal: Gold Silver Bronze Bronze4 AV Metal Value: 0.812 0.711 0.619 0.602

5Benefit Relativity Factor: 0.880 0.720 0.588 0.558

6 Plan Type: HMO HMO HMO HMO

7Plan Name:

Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15Core Bronze

H.S.A. -158 Plan ID : 80473WA0840002 80473WA0840001 80473WA0830001 80473WA08200019 Exchange Plan? No No No No

10Projected 2015 Member Months 32,016 35,232 79,368 79,368

11Composite Benefit Relativity Factor 0.657

12

Non-Essential Health Benefit % of Allowed Claims 0.013

13

Composite Benefit Relativity Factor Reduced for Non-EHB 0.649

14

Paid to Allowed Average Factor in Worksheet 1 0.649

Group Health Cooperative Individual and Family Core3 Direct

80473WA084

80473WA080

Group Health Cooperative Individual and Family Core3

Exchange



9. Risk Adjustment and Reinsurance

a. Projected Risk Adjustments PMPM There are significant unknown shifts in the risk mix of the individual market pool and evidence that 2013 population is substantially reflective of the market risk. Therefore we are projecting that our pool will be consistent with the market change in morbidity and we are not proposing any risk adjustment payment adjustments to the rates. The risk adjustment user fee of $.08 PMPM (as published in the HHS Notice of Benefit and Payment Parameters, 3/11/2014) is included in this category per URRT instructions.

b. Projected ACA Reinsurance Recoveries Net of Reinsurance Premium

The parameters used to calculate expected recoveries for the Reinsurance program are as published in the HHS Notice of Benefit and Payment Parameters, 3/11/2014 are:

• $70,000 claims attachment point

• $250,000 reinsurance cap

• 50% coinsurance rate Expected reinsurance as a percent of claims was calculated using a continuance table of annual paid claims from the experience of the comprehensive individual plans calendar year 2013 experience. The comprehensive plan benefits have similar covered benefits and cost sharing as the new 2015 individual plans. The reinsurance parameters were applied to the continuance table and produced a value of 6.3% of paid claims for the reinsurance claims recovery amount. The expected net total reinsurance recovery amount was calculated on a pmpm basis for the 2015 plans using this 6.3% of paid claim pmpm amount and netting out the $3.67 pmpm reinsurance premium payable. We assumed that HHS will remit the full reimbursement to the carriers for their reinsurance claims so that the $3.67 reinsurance pmpm assessment would produce federal government funds sufficient to cover 100% of the reinsured claims. The reinsurance contribution was allocated as a pmpm charge while the reinsurance payment was allocated as percent of premium for each plan. Please see Section 15 for the Plan Adjusted Index Rate formula showing exactly how the reinsurance payments and contribution were factored in. The aggregate projected ACA reinsurance recoveries net of reinsurance premium is $16.97 PMPM per the URRT. Please see Exhibit 21 Reinsurance Calculation in the WA state rate filing for more detail behind the reinsurance claims recovery calculation.



10. Non-Benefit Expenses and Profit & Risk

a. Administrative Expense Load The administrative expense load used for rating includes both the company operating expense and the commissions paid to brokers. The 2013 statutory operating expense was used as the basis to project the 2015 operating expense. The statutory operating expense was calculated as a combined pmpm for GHC and GHO individual plans. This is appropriate because of the existing administrative services agreement between GHO and GHC whereby GHC provides such services to GHO. This effectively produces administrative costs that are substantially similar between the two companies. The 2013 statutory operating expense was calculated as a total pmpm of $40.83 for individual GHO and individual GHC combined. Then 73.2% was assigned of those amounts was assigned to be fixed pmpm costs and 26.8% was assigned to be variable cost (varies with claims level). The percentage breakout was determined using the GHC and GHO combined 2013 annual statement Part 3 – Analysis of Expenses. The fixed pmpm costs were trended at 3% annual trend to 2015 to give fixed pmpms of $31.71 for individual GHO and individual GHC combined. The variable costs pmpm were divided by 2013 premium to calculate them as a percent of premium which gave 4.23% for individual GHC. The trended fixed cost pmpms and the variable cost pmpm combined to give a total average operating expense pmpms for the 2015 plans of $48.42 for individual GHC. The 2015 commission loads as a percent of premium were derived by taking the statutory 2013 commission divided by the 2013 premium and then adjusting for reduced commission percents in 2015. The 2015 commission loads as a percent of premium are 1.68% for individual GHC. The administrative expense load is applied as the same overall percent for all products and plans. Please see Exhibit 8 Administrative Cost Calculation, Exhibit 9 Commission Percentage Calculation, and Exhibit 16 Administrative Cost Trend & Variable Component in the WA state rate filing for more detail behind the administrative expense load.

b. Profit (or Contribution to Surplus) & Risk Margin i. GHC Contribution to Surplus The pricing was developed with a target before tax contribution to surplus of 2%. This level of contribution to surplus is necessary because of individual GHC’s marginal financial performance.



These margins are reduced by the anticipated investment income attributed to this line of business as stipulated by Washington State regulations. The Investment income offset is calculated at 0.01%. Please see the WAC 284-43-945 Investment Income exhibit in the WA state rate filing for more detail behind the investment income credit calculation. This margin is consistent with prior rate filings’ requested margins. The margin load as a percent does not vary by product or plan. ii. Risk and Contingency Margin This was developed by calculating the standard deviation as a percent of 12 months rolling allowed claims pmpm (the commercial population experience base used for trend) and applying actuarial judgment to reflect the combined impact of the risk mitigation programs in place for 2015 and the additional sources of risk introduced by such wide ranging change to the market structure. This requires balancing the factors that contribute to an increase in risk for 2015 with those that will mitigate risk (see below). The risk and contingency margin load of 1% also does not vary by product or plan.

Decreased Risk • Risk Adjustment – The risk adjustment program is designed to

compensate for population risk relative to the overall risk pool. To the extent that this program works as intended, there is some protection from adverse population morbidity risk.

• Reinsurance – The reinsurance program should dampen some of the volatility introduced by enrollees with high cost claims in the individual market.

Increased Risk • Population shift – This is one of the greatest unknowns. It

includes items such as changes in the size of the overall market, the characteristics of the new entrants into the market, and the magnitude of pent up demand for those new entrants.

• Benefit changes – The required new benefits are more comprehensive and of new types than have been offered before in the individual market. This combined with unknowns about the newly insured population contributes to a risk of health status benefit selection and induced utilization effects that are not fully compensated for by risk adjustment.

• 3Rs program uncertainty – Even though the Risk Adjustment, Risk Corridors, and Reinsurance programs are intended to mitigate risk, they actually introduce risk as well. For example, the individual



market rates were set using the reinsurance program parameters to estimate a reinsurance claims payment. If in total there is not enough money collected to fund the calculated reinsurance claims payments then all carriers will receive a proportional cutback in the reinsurance amount they receive. The likelihood of this happening is a risk that is hard to quantify, in part because of uncertainties in the health status and number of newly insured members. If the nationwide net effect of risk corridors is a transfer of monies from the government to the carriers, the uncertainties around the federal budget could put that transfer in question. Risk adjustment relies on a model that is untested in the target population and is subject to statistical variations between actual and predicted risk – as demonstrated in the September 2012 SOA Study – “Uncertainty in Risk Adjustment” by Syed Mehmud and Rong Yi. In addition there continue to be significant changes to the operations of the 3R programs and market rules in general.

• Pricing risk: The pricing restrictions (such as the elimination of claim experience from area factors) increase the reliance on the accuracy of membership projections.

• Other: There are numerous other provisions that are changing such as: mix of business, definition of rating area, 3:1 mandated age rating ratio, elimination of underwriting, elimination of the state high risk pool, etc.

c. Taxes and Fees The Taxes and Fees and other retention loads are: Item Description PMPM % Premium

1 Administrative Charge - Fixed $31.71 8.03%2 Administrative Charge - Variable $16.71 4.23%3 Commissions $6.62 1.68%4 Subtotal = URRT Admininstrative Cost $55.04 13.93%5 Premium Tax $7.90 2.00%6 WA Office of the Insurance Commissioner regulatory surcharge $0.37 0.093%7 ACA Carrier Fee [Section 9010 of the ACA] $3.94 1.00%8 WSHIP (Washington State Health Insurance Pool) assessment fee $1.19 0.30%9 Exchange Fees estimated collected for 2015 $1.91 0.48%

10 ACA (Section 4375 of ACA) PCORI fee – $2.28 Per member per year $0.19 0.05%11 Subtotal = URRT Taxes & Fees $15.50 3.92%12 Contribution to Surplus Load $7.90 2.00%13 Risk and Contingency Fee $3.95 1.00%14 Investment Income credit ($0.04) -0.01%15 Subtotal = URRT Profit & Risk $11.81 2.99%16 Grand Total $82.35 20.85%17 URRT Premium $394.99 100.00%18 URRT Paid Claims Check (17. - 16.) and Projected Loss Ratio $312.64 79.15%



Premium tax is the WA state premium tax of 2% per RCW 48.14.020. The WA OIC regulatory surcharge is the charge assessed carriers per RCW 48.02.190. The ACA carrier fee is the carrier fee assessed by the federal government per section 9010 of the ACA. The Washington State Health Insurance Pool assessment fee is the charge assessed carriers for deficits in operation of the pool per RCW 48.41.090. The ACA PCORI (Patient-Centered Outcomes Research Institute) is a per member per month fee assessed by the federal government per section 4375 of the ACA. Exchange fees are the fees carriers pay to support the operation of the WA state Exchange. Exchange user fees are applied as a pmpm adjustment to the Index Rate to calculate the Market Adjusted Index Rate. See the Section 14 of this memorandum for the full calculation. The pmpm Exchange user fee is calculated as the total assessed fee of $4.19 pmpm times the percent of individual GHC members expected on the Exchange (45.5%) = $1.91 pmpm. The 45.5% figure is the actual percentage of GHC individual plan membership on the Exchange for March 2014.

11. Projected Loss Ratio The projected 2015 MLR for GHC individual plans of 86.1% was derived using the federally prescribed method. Please see Exhibit 20 Projected MLR in the WA state rate filing for more detail behind the MLR calculation. 12. Single Risk Pool The single risk pool used in this filing conforms to the requirements of 45 CFR 156.80 and the requirements delineated in the Part III Actuarial Memorandum instructions published March 20, 2014. The single risk pool includes all current individual plan members, including a small component of individuals in associations. 13. Index Rate The following table provides support for the index rate in the 2013 experience period.

Allowed Claims PMPMa 2013 Total $84,131,932 $311.81b 2013 Adult Vision Exam $977,563 $3.62c 2013 Adult Optical Hardware $349,767 $1.30d 2013 Experience Index Rate (=a-b-c) $82,804,602 $306.89



The adult vision exam and adult optical hardware allowed claims in 2013 were identified by Group Health data warehouse benefit categorization for adult ages (19 years of age or older). The Index Rate for the projection period in Worksheet 1 equals the Projected Allowed Experience Claims pmpm for only essential health benefits. The non-essential benefits of adult vision exam and adult optical hardware were removed by calculating “Other” projection factors. Essential health benefits of pediatric vision exam, pediatric optical hardware, pediatric dental, maternity coverage and prescription drug coverage were added by calculating “Other” projection factors. Please see Section 5(b) for a description of the benefit adjustments made and their impact on claims. The Index Rate calculation follows the same methodology as the projection including non-essential benefits and includes the same factors for:

• Population morbidity • Trend • Administrative Expense Load • Profit & Risk Load • Taxes and Fees

The table below summarizes the Index Rate calculation. The Index Rate is $501.54 pmpm.

Projection Period: 1/1/2015 to 12/31/20152013 Exp.

Period Allowed Claims

Adj't. from Experience to

Projection Period

Benefit Category PMPM

Pop'l risk Morbidit

y Other Cost UtilUtilization per 1,000

Average Cost/Servi

ce PMPMInpatient Hospital $71.07 1.137 1.129 1.039 1.037 204.69 $6,207.17 $105.88Outpatient Hospital $62.80 1.137 1.068 1.039 1.037 953.88 $1,113.46 $88.51Professional $57.68 1.137 1.044 1.039 1.037 4,143.69 $230.12 $79.46Other Medical $86.44 1.137 1.169 1.039 1.037 9,806.24 $163.18 $133.35Capitation $0.00 1.137 1.068 1.000 1.000 0.26 $50.35 $0.00Prescription Drug 33.83 1.137 1.936 1.077 1.045 11,255.52 $100.58 $94.34Total $311.81 $501.54

Annualized Trend Factors

Projections, after credibility Adjustment



14. Market Adjusted Index Rate The following table shows the derivation of the Market Adjusted Index Rate and the source of the modifiers:

PMPM

a2015 Index Rate (from URRT) $501.54

b

Federal Reinsurance Program Adjustment PMPM (from URRT) ($16.97)

cRisk Adjustment (User Fee) PMPM (From URRT) $0.08

d

Exchange User Fee Adjustment (=$4.19 pmpm assessment x 45.5% Exchange membership participation) $1.91

e

2015 Market Adjusted Index Rate (sum of a through d) $486.56



15. Plan Adjusted Index Rates

a. Tables with derivation of the Plan Adjusted Index Rates:

Product:



Bronze Exchange




Individual and Family Catastrophic

ExchangeItem Product ID: 80473WA079 80473WA078 80473WA081

Metal: Gold Silver Bronze Bronze Catastrophica Market Adjusted Index Rate PMPM $486.56 $486.56 $486.56 $486.56 $486.56b Index Rate Allowed Claims PMPM $501.54 $501.54 $501.54 $501.54 $501.54c Starting AV Value (AV Metal Value) 0.812 0.711 0.619 0.602 0.598d Catastrophic Plan Eligibility Impact 1.000 1.000 1.000 1.000 0.880e Demand Elasticity Adj. 1.070 1.000 0.937 0.925 0.922f Non-EHB Benefits 1.013 1.013 1.013 1.013 1.013

gAdjustment to Pediatric Dental Benefit (Remove from Exchange Plans, Leaner Benefit for HSA Direct Plan) 0.986 0.986 0.986 0.986 0.986

h Benefit Relativity Factor (= c x d x e x f x g) 0.867 0.710 0.580 0.557 0.484i Paid Claims (= b x h) $435.08 $356.14 $290.80 $279.17 $242.78j Non-EHB Benefits Claims PMPM $5.64 $4.62 $3.77 $3.62 $3.15k Reinsurance Premium PMPM $3.67 $3.67 $3.67 $3.67 $3.67l Total Admin, Taxes & Fees, Profit, R&C % of Premium 20.8% 20.8% 20.8% 20.8% 20.8%

m Reinsurance Recovery as a % of Premium 5.2% 5.2% 5.2% 5.2% 5.2%n Risk Adjustments (User Fee) $0.08 $0.08 $0.08 $0.08 $0.08o 2015 Average Premium Rate PMPM [= (i + k + n) / (1 - l + m)] $520.07 $426.53 $349.09 $335.30 $292.18

p Composite Age Factor / Composite Age-Tobacco Use Factor 0.991 0.991 0.991 0.991 0.991q URRT Plan Adjusted Index Rate $515.53 $422.80 $346.04 $332.37 $289.62r URRT AV Pricing Value (= q / Exchange Silver q value) 1.219 1.000 0.818 0.786 0.685

Plan Name: Core3 Gold -15 Core3 Silver -15 Core3 Bronze - 15Core Bronze

H.S.A. -15 Core Basics Plus -15Plan ID : 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001

Group Health Cooperative Individual and Family Core3 Exchange

80473WA080



Product:





Item Product ID: 80473WA083 80473WA082Metal: Gold Silver Bronze Bronze

a Market Adjusted Index Rate PMPM $486.56 $486.56 $486.56 $486.56b Index Rate Allowed Claims PMPM $501.54 $501.54 $501.54 $501.54c Starting AV Value (AV Metal Value) 0.812 0.711 0.619 0.602d Catastrophic Plan Eligibility Impact 1.000 1.000 1.000 1.000e Demand Elasticity Adj. 1.070 1.000 0.937 0.925f Non-EHB Benefits 1.013 1.013 1.013 1.013

gAdjustment to Pediatric Dental Benefit (Remove from Exchange Plans, Leaner Benefit for HSA Direct Plan) 1.000 1.000 1.000 0.989

h Benefit Relativity Factor (= c x d x e x f x g) 0.880 0.720 0.588 0.558i Paid Claims (= b x h) $441.21 $361.16 $294.90 $279.88j Non-EHB Benefits Claims PMPM $5.72 $4.68 $3.82 $3.63k Reinsurance Premium PMPM $3.67 $3.67 $3.67 $3.67l Total Admin, Taxes & Fees, Profit, R&C % of Premium 20.8% 20.8% 20.8% 20.8%

m Reinsurance Recovery as a % of Premium 5.2% 5.2% 5.2% 5.2%n Risk Adjustments (User Fee) $0.08 $0.08 $0.08 $0.08o 2015 Average Premium Rate PMPM [= (i + k + n) / (1 - l + m)] $527.34 $432.47 $353.95 $336.15

p Composite Age Factor / Composite Age-Tobacco Use Factor 0.991 0.991 0.991 0.991q URRT Plan Adjusted Index Rate $522.73 $428.69 $350.85 $333.21r URRT AV Pricing Value (= q / Exchange Silver q value) 1.236 1.014 0.830 0.788

Plan Name: Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15Core Bronze

H.S.A. -15Plan ID : 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001


80473WA084

b. Development of Modifiers (refer to above tables) Item c: This is the AV from the HHS AV calculator for the plan. Item d: To estimate a factor that reflects the difference in anticipated demographics and morbidity of the catastrophic population we assumed that the population likely to enroll in the catastrophic plan would reflect the individual risk pool prior to ACA reforms therefore we set the catastrophic plan adjustment to remove the overall population morbidity adjustment of 1.1367 – which results in a plan level adjustment of 1/1.1367 = 0.880 Item e: Each plan was adjusted for demand elasticity as compared to the Core3 Silver-15 Exchange plan. Economic research indicates that health care, like other commodities, is subject to demand elasticity. That is, lowering the price of a commodity increases utilization and raising the price decreases utilization for a given individual. Demand elasticity adjusts the total utilization only for the differences in an individual’s utilization based on plan cost-sharing. It does not adjust for the health status of that individual. A demand elasticity factor of -0.2 was used as consistent with published studies in the 2002 RAND study “The Elasticity of Demand for Health Care: A Review of the Literature” by Jeanne S. Ringel, Susan D.Hosek, Ben A. Vollaard, and Sergej Mahnovski.



The percent utilization difference = (The percent difference in member cost sharing/starting value of cost sharing) * (-0.2). From that starting point, the impact of additional benefits or removed benefits was reflected by calculating their expected allowed claims cost PMPM as a percentage of EHB allowed claims PMPM and applying that factor to the demand-elasticity adjusted AV. Item f: The Non-EHB percentage = the Projected Allowed Experience Claims PMPM from the URRT divided by the Index Rate. Item g: Let: a = Index Rate

b = Allowed Pediatric Dental Cost c = Capitation Rate for HSA Pediatric Dental

d = Capitation Rate for non-HSA Pediatric Dental

The reduction factor for HSA pediatric dental rate then = 1 – (1 – c/d) * (b/a) Item k: See Section 9(b). Item l: See Section 10(c). Item m: See Section 9(b). The reinsurance recovery as a percent of claims was converted to a percent of premium by taking the reinsurance recovery as a percent of claims * URRT Projected Incurred Claims, Before ACA Reinsurance & Risk Adjustment PMPM / URRT Single Risk Pool Gross Premium Avg. Rate PMPM. Item n: See Section 9(a). Item p: This adjustment removes the portion of the cost expected to be recouped through the tobacco user surcharge per the Actuarial Memorandum instructions. In effect, it normalizes the average premium rate for the age-tobacco use factor. A composite age-tobacco use factor is needed because the tobacco use factor effect varies by age and is different for age band 0-20 (no tobacco use load) versus age bands 21+ (0.20 tobacco use load). The normalized average premium rate is then multiplied by the composite age factor to add back in the effect of the age profile of the population. See Section 16 (b) for the composite age factor derivation. The composite age-tobacco use factor is derived using the March 2014 membership age band table in Section 16(a) and the following table of information for the March 2014 GHC Individual plan membership:

Non-Tobacco user Tobacco user Total

Age 21+ Tobacco user Member Months: 28,914 1,409 30,323 Rating Factor 1.0 1.2 21+ Member Months Percent of Total 95.4% 4.6% 100.0% Tobacco use Load Factor

-

0.200



Total Composite Age/Tobacco use Factor (Used to Calculate Plan Adjusted Index Rate):

1.7233

Let: a = Non-tobacco user Load Factor = 0

b = Sum of Age Factor * Membership for Age Bands 21 and Over c = Non-tobacco user Percent Total Membership

d = Tobacco user Load Factor = 0.2 e = Tobacco user Percent Total Membership f = Age Factor * Membership for Age Band 0-20 g = Total Membership

The composite age-tobacco use factor = (a*b*c + d*b*e + f) / g

c. Derivation of Plan Adjusted Index Rate The step by step derivation of the Plan Adjusted Index Rate is shown in the table in Section 15(a).

16. Calibration

a. The following tables provide the derivation of the calibration factors and their application to the Plan Adjusted Index Rate:

AGEBAND Total 3-2014 Members * ACA Age Factor

0-20 4,855 0.635 21 395 1.000 22 377 1.000 23 377 1.000 24 327 1.000 25 383 1.004 26 628 1.024 27 598 1.048 28 531 1.087 29 571 1.119 30 545 1.135 31 482 1.159 32 499 1.183 33 504 1.198 34 523 1.214 35 504 1.222 36 452 1.230



37 467 1.238 38 450 1.246 39 514 1.262 40 499 1.278 41 517 1.302 42 543 1.325 43 585 1.357 44 618 1.397 45 599 1.444 46 582 1.500 47 584 1.563 48 628 1.635 49 685 1.706 50 708 1.786 51 799 1.865 52 763 1.952 53 846 2.040 54 841 2.135 55 887 2.230 56 939 2.333 57 961 2.437 58 1,020 2.548 59 1,041 2.603 60 1,181 2.714 61 1,272 2.810 62 1,371 2.873 63 1,385 2.952

64+ 1,342 3.000 Grand Total 35,178 Total Age 21+ 30,323 Total Age 0-20 4,855 * 0-20 Age band doesn't include 4 or more children in a family.



Average Age Associated with Composite Age Factor:Composite Age Factor: 1.7083 49

Rate Area 1 2 4 5 CompositeArea Factor 1.000 1.037 0.956 1.004 1.011Member Months 13,414 14,738 3,769 3,405 35,326Percent Members In Area 38.0% 41.7% 10.7% 9.6% 100.0%Area Load 0.000 0.037 -0.044 0.004

b. Age Curve Calibration The composite age factor = Sum of the ACA age factor multiplied by the March 2014 GHC individual plan enrollment in each age band and then divided by the total enrollment counting all members. The enrollment in the 0-20 age band did not include 4 or more children in a family. The average age associated with the composite age factor is the ACA age band that most closely corresponds to the composite age factor (age 49). Since this method uses the ACA standard age curve and counts no more than 3 children in a family, it conforms to the rating rules in 45 CFR 147.102. See section 17 for a demonstration of how the Plan Adjusted Index Rate generates the Consumer Adjusted Premium Rate. The Consumer Adjusted Rate is the Plan Adjusted Index Rate calibrated for age and area.

c. Geographic Factor Calibration See the Rate Area table in section 16(a) for a listing of all geographic rating factors applied to the Plan Adjusted Index Rate. The composite area load of 1.011 in that table is the geographic factor calibration. See section 24(a) of this memorandum for the development of the geographic rating factors. See section 17 for a demonstration of how the Plan Adjusted Index Rate generates the Consumer Adjusted Premium Rate. The Consumer Adjusted Rate is the Plan Adjusted Index Rate calibrated for age and area.

17. Consumer Adjusted Premium Rates The following is a description of how the Plan Adjusted Index Rate is adjusted to arrive at each plan’s Consumer Adjusted Premium Rate. Let: a = Plan Adjusted Index Rate b = Composite Age Factor c = Composite Geographic Area Factor

d = ACA Age Band Factor



e = Geographic Area Factor f = Tobacco Use Factor

The rate for a given age band, geographic area and tobacco user status = (a / (b * c)) * d * e * f See section 16 of this memorandum for the geographic area factors, tobacco use factors and ACA age factors. The following tables show the derivation of the age, area calibrated Plan Adjusted Index Rates for each plan. These are the rates that the age, area and tobacco use factors apply to. They also show the derivation of the Consumer Adjusted Premium Rate for a non-tobacco user member, age 30, in area 1. Product ID: 80473WA080 80473WA080 80473WA079 80473WA078 80473WA081Metal Level: Gold Silver Bronze Bronze Catastrophic

Plan Name: Core3 Gold -15 Core3 Silver -15 Core3 Bronze - 15Core Bronze H.S.A. -15

Core Basics Plus -15

Plan ID: 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001Exchange Plan?: Yes Yes Yes Yes YesPlan Adjusted Index Rate PMPM From Unified Rating Template: $515.53 $422.80 $346.04 $332.37 $289.62 Composite Factor For Age,Area (=composite age factor times composite area factor): 1.73 1.73 1.73 1.73 1.73 Age, Area Calibrated Plan Adjusted Index Rate (=Plan Adjusted Rate Index Rate Divided by Composite Age,Area Factor): $298.46 $244.78 $200.34 $192.42 $167.68

Consumer Adjusted Premium Rate for Age Band 30, Area 1, Non-Tobacco User (=Calibrated Rate x Age Factor x Area Factor x Tobacco Use Factor): $338.76 $277.82 $227.38 $218.40 $190.31

FactorAge Band: 30 1.135Area: 1 1.000Tobacco User Status: Non-Tobacco User 1.0



Product ID: 80473WA084 80473WA084 80473WA083 80473WA082Metal Level: Gold Silver Bronze Bronze

Plan Name: Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15Core Bronze H.S.A. -15

Plan ID: 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001Exchange Plan?: No No No NoPlan Adjusted Index Rate PMPM From Unified Rating Template: $522.73 $428.69 $350.85 $333.21 Composite Factor For Age,Area (=composite age factor times composite area factor): 1.73 1.73 1.73 1.73 Age, Area Calibrated Plan Adjusted Index Rate (=Plan Adjusted Rate Index Rate Divided by Composite Age,Area Factor): $302.63 $248.19 $203.12 $192.91

Consumer Adjusted Premium Rate for Age Band 30, Area 1, Non-Tobacco User (=Calibrated Rate x Age Factor x Area Factor x Tobacco Use Factor): $343.49 $281.70 $230.55 $218.95

FactorAge Band: 30 1.135Area: 1 1.000Tobacco User Status: Non-Tobacco User 1.000 18. AV Metal Values The AV Metal Values included in Worksheet 2 of the Part I Unified Rate Review Template are entirely based on the AV Calculator.



19. AV Pricing Values Please see the tables in Section 15(a) for the portion of the Benefit Relativity Factors (AV Pricing Values) that are attributable to each of the allowable modifiers to the Index Rate as allowed by 45 CFR 156.80(d)(2). See Section 15(b) for a discussion on the demand elasticity factor. As noted in that section, demand elasticity is an economic factor that adjusts the total utilization only for the differences in an individual’s utilization based on plan cost-sharing. It does not adjust for the health status of that individual. The AV Pricing Values are calculated by dividing the Plan Adjusted Index Rate for each Plan by the Plan Adjusted Index Rate for the reference plan (Core3 Silver-15 Exchange plan). 20. Membership Projections The 2015 member counts by plan were derived using March 2014 individual plan membership and by mapping the member’s 2014 plan to the most comparable 2015 plan. The 2015 projected member months were calculated as twelve times the 2015 projected member counts. Similarly, we used the March 2014 member counts by subsidy level to project the 2015 member months by subsidy level shown below.

2015 Member MonthsStandard Silver Core3 38,508 200%-250% FPL Silver Core3 19,944 150%-200% FPL Silver Core3 47,676 <150% FPL Silver Core3 12,024 Total Silver Core3 118,152 21. Terminated Products 2013 Plans Welcome 1000, Welcome 2000, Welcome 3500, HSA 2000, Grandfathered High Option, Grandfathered 500, Grandfathered 1000 2014 Plans

Product ID: 80473WA055 80473WA055 80473WA055 80473WA054 Metal Level: Gold Silver Bronze Catastrophic Plan Name: Core Gold Core Silver Core Bronze Core Basics Plus Plan ID: 80473WA0550007 80473WA0550003 80473WA0680002 80473WA0540001 Exchange Plan?: Yes Yes Yes Yes



80473WA066 80473WA066 80473WA067 Gold Silver Bronze

Core 3 Gold Core 3 Silver HealthPays Bronze

80473WA0660002 80473WA0660001 80473WA0670001 No No No

22. Plan Type The drop down box in Worksheet 2 for plan type accurately describes each plan type. 23. Warning Alerts and Template Issues

a. Warning Alerts There are no warnings.

b. Unified Rate Review Template Issues 1. The “Plan Adjusted Index Rate” and “Total Premium (TP)” in

Section IV of Worksheet 2 don’t match exactly to the “Worksheet 1 Total” check amounts due to the Plan Adjusted Index Rate in Worksheet2 Section IV having the overall population tobacco use premium rate load taken out per the Actuarial Memorandum instructions. The total premium in this section is calculated using the Plan Adjusted Index Rate.

24. Effective Rate Review Information

a. Area Factors The main driver of Group Health contractual cost differences by area is inpatient hospital costs. We used case mix adjusted allowed inpatient claims per day for our entire Group Health commercial block of business for the experience period October 2011 to September 2012, paid through Dec 2012 excluding selected specialized facilities that typically serve members from all geographic regions. We calculated the ratio of adjusted allowed per day to the Index Area 1 adjusted allowed per day to get the inpatient specific relative cost. We weighted this number at 22% of allowed claims attributable to Inpatient Claims and the other 78% of allowed claims at a 1.0 relative cost factor to arrive at the final proposed area factor. The final area factors comply with WAC 284-170-250 regulation with Area 1 – King County as the Index area at 1.0 and the ratio of the highest to lowest area factor at 1.086 which is less than the 1.15 permitted.



Rating Area Case Mix Adjusted Allowed

per Day

Case Mix Adjusted Allowed per day relative to

Area 1

Final Area Factor

Area 1 $ 3,577 1.000 1.000 Area 2 $ 4,179 1.168 1.037 Area 4 $ 2,857 0.799 0.956 Area 5 $ 3,634 1.016 1.004 Ratio

Highest/Lowest (2)/(4)

1.085

b. Tobacco Use Factor

We are applying a 1.2 premium factor for tobacco use. This is the same as our current factor applied for tobacco use. A paid claims analysis of 2013 tobacco versus non-tobacco users supports this factor as reasonable and appropriate.

Premium Paid Claims Paid Loss

Ratio Non-Tobacco User $49,938,963 $39,034,291 78.2% Tobacco User $ 4,437,809 $ 5,505,326 124.1%

c. Age Factors For purposes of producing the final rates, we are using the CMS Standard Age-Curve provided by the Department of Health and Human Services.

25. Reliance We relied on the information distributed through the following: • SERFF • Society of Actuaries - Base population morbidity information used was

provided by the study “Cost of the Future Newly Insured under the Affordable Care Act (ACA) – March 2013” by the Society of Actuaries

• Guidance Washington State Office of the Insurance Commissioner • Group Health data warehouse information provided by Ben Choi • Forms, rules and instructions from HHS • Pediatric dental information from United Concordia • Published research on demand elasticity in the 2002 RAND study “The

Elasticity of Demand for Health Care: A Review of the Literature” by Jeanne S. Ringel, Susan D. Hosek, Ben A. Vollaard, Sergej Mahnovski.



26. Required Items per Actuarial Standards of Practice (ASOP) 41

Identification of Actuarial Documents Submitted with this rate filing as actuarial documents are the Part I Unified Rate Review Template spreadsheet, the HHS Part II document, and the HHS Part III document (Actuarial Memorandum). Required Disclosures The actuarial findings, the methods, procedures, assumptions, and data used in this filing are primarily delineated by the Part I Unified Rate Review Template and this Actuarial Memorandum. The HHS Part II document contains a short consumer disclosure of the results. Intended users of the actuarial report This report is intended for the use of CCIIO, HHS, and regulators for the State of Washington for their review of the rates for the 2015 plans. Scope and intended purpose of the engagement or assignment The scope and intended purpose of the filing is to provide the calculation and actuarial justification of the rates for the 2015 plans. Acknowledgement of qualification as specified in the Section Qualification Standards Such acknowledgement is given in the Actuarial Certification below.

Any cautions about risk and uncertainty A discussion of risk and uncertainties is given in section 10. Non-Benefit Expenses and Profit & Risk of this memorandum. Any limitations or constraints on the use or applicability of the actuarial findings contained within the actuarial communication including, if appropriate, a statement that the communication should not be relied upon for any other purpose The actuarial findings are only intended for the development of the rates for the 2015 plans and should not be relied on for any other purpose. Any conflict of interest There were no conflicts of interest in the preparation of this filing.



Any information on which the actuary relied that has a material impact on the actuarial findings and for which the actuary does not assume responsibility Please see section 25. Reliance of this memorandum. Information dates The dates associated with the data are communicated in this Actuarial Memorandum and the Part I Unified Rate Review Template. Subsequent event(s) (if any) There were no events that: a) became known after the latest information date but before this report was issued b) may have a material effect on the actuarial findings and c) were impractical to include in this report before it was issued. If appropriate, the documents comprising the actuarial report The written actuarial report documents consist of HHS Part III (Actuarial Memorandum) and HHS Part II (Consumer Disclosure Summary). The Part I Unified Rate Review Template spreadsheet contains data and calculations used to produce the average rates for the 2015 plans.



27. Actuarial Certification Opining Actuary Certification: I Mark Ackerman am a member of AAA and in good standing. I have the education and experience necessary to perform this work. I meet the qualification standards of the Academy/Society. I have developed rates in accordance with the appropriate ASOPs (No. 5, No. 8, No. 12, No. 23, No. 25, No. 26 and No. 41) and the professional code of conduct. I hereby certify the projected index rate is:

o In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.80(d)(1)),

o Developed in compliance with the applicable Actuarial Standards of Practice o Reasonable in relation to the benefits provided and population anticipated

to be covered o Neither excessive nor deficient

I certify that the index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(2) were used to generate plan level rates. I certify that the percent of total premium that represents essential health benefits included in Worksheet 2, Selections II and IV were calculated in accordance with actuarial standards of practice. I certify that the AV Calculator was used to determine the AV Metal Values shown in Worksheet 2 of the Part I Unified Rate Review Template for all plans except those specified in the certification. If an alternate methodology was used to calculate the AV Metal Value for at least one plan offered, a copy of the actuarial certification required by 45 CFR Part 156, section 156.135 must be included. The certification must be signed by a member of the American Academy of Actuaries, and must indicate that the values were developed in accordance with generally accepted actuarial principles and methodologies. I have relied on the items listed in section 25. Reliance of this memorandum in the preparation of this filing. Signed: __Mark Ackerman _(electronic signature)_________ Mark L. Ackerman, ASA, MAAA Title: Pricing Actuary Actuarial & Underwriting Group Health Cooperative Date: April 28, 2014

1/1/2015 Group Health Cooperative Individual Rate Filing HHS Part II Page 1 of 2

Group Health Cooperative Individual Products

Rates Effective January 1, 2015 through December 31, 2015 Written Explanation of the Rate Increase - Part II

Reason for Rate Increase All of our current individual plans are being replaced with new plans effective January 1, 2015. Scope and Range of The Rate Increase There is no calculated rate increase since these are new plans. Financial Experience of the Products The following information uses member months and premium adjusted for retroactivity along with statutory financial statement claims and expenses.

From To From To From To1/1/2013 12/31/2013 1/1/2012 12/31/2012 1/1/2011 12/31/2011

Member Months

Earned Premium

Paid Claims

Beginning Claim Reserve

Ending Claim Reserve

Incurred Claims

Expenses

Gain/Loss

Loss Ratio Percentage

270,003 213,402 152,982

ExperiencePeriod

SecondPrior Period

FirstPrior Period

89.14%

$59,841,012

$51,104,076

($3,893,178)

$3,630,772

$50,841,670

$12,125,113

($3,125,771)

84.96%

$5,757,995

$62,012,144

$14,451,713

($6,897,041)

$69,566,816

$59,884,921

($3,630,772)

($3,232,829)

89.17%

$48,723,387

$42,227,693

($2,676,433)

$3,893,178

$43,444,438

$8,511,778

Note: Includes Group Conversion plans.

1/1/2015 Group Health Cooperative Individual Rate Filing HHS Part II Page 2 of 2

Changes in Medical Service Costs A base 8.6% trend was used to project allowed claims from the experience period of calendar 2013 to the rating period of 1/1/2015 to 12/31/2015. Population morbidity is expected to increase costs by 13.7%. Additional benefits are expected to increase costs to the pool by 14%. Reinsurance recovery claims through the federal government net of reinsurance premium paid is expected to lower claims costs by 5%. Changes in Benefits The new 2015 plans have different benefits than the 2013 plans used to derive the 2015 rates. Benefit changes were made in order to comply with Affordable Care Act essential health benefit requirements. These primarily consist of the addition of pediatric dental, pediatric vision services for all plans, maternity coverage for all plans and prescription drug coverage for all plans. Non-essential benefits consisting of adult vision exam services were added to all plans. Administrative Costs and Anticipated Contribution to Surplus Item Description [all amounts converted to a percent of premium] Amount

1 Administrative Charge 12.26%2 Commissions 1.68%3 Premium Tax 2.00%4 WA Office of the Insurance Commissioner regulatory surcharge 0.09%5 ACA Carrier Fee (Section 9010 of the ACA) 1.00%6 WSHIP (Washington State Health Insurance Pool) assessment fee 0.30%7 Exchange Fees estimated collected for 2015 0.48%8 ACA (Section 4375 of ACA) PCORI fee – $2.28 Per member per

year [converted to percent of premium]0.05%

9 Contribution to Surplus Load 2.00%10 Risk and Contingency Fee 1.00%11 Investment Income credit -0.01%12 Total (percent of premium) 20.85%

1 of 2

1

2

3

4

5

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131415161718192021

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2324252627282930313233343536373839404142434445464748

4950

A B C D E F G H I J K L M N O P Q R S T U V W X Y

Unified Rate Review v2.0.2

Company Legal Name: Group Health Cooperative State: WAHIOS Issuer ID: 80473 Market: IndividualEffective Date of Rate Change(s): 1/1/2015

Market Level Calculations (Same for all Plans)

Section I: Experience period dataExperience Period: 1/1/2013 to 12/31/2013

Experience Period Aggregate Amount PMPM % of Prem

Premiums (net of MLR Rebate) in Experience Period: $69,744,636 $258.49 100.00%Incurred Claims in Experience Period $62,892,841 233.09 90.18%Allowed Claims: $84,131,932 311.81 120.63%Index Rate of Experience Period $306.89Experience Period Member Months 269,820

Section II: Allowed Claims, PMPM basisExperience Period Projection Period: 1/1/2015 to 12/31/2015 Mid-point to Mid-point, Experience to Projection: 24 months

on Actual Experience AllowedAdj't. from Experience to

Projection Period Projections, before credibility Adjustment Credibility Manual

Benefit CategoryUtilization

DescriptionUtilization per

1,000Average

Cost/Service PMPMPop'l risk Morbidity Other Cost Util

Utilization per 1,000

Average Cost/Service PMPM

Utilization per 1,000

Average Cost/Service PMPM

Inpatient Hospital Days 167.55 $5,089.70 $71.07 1.137 1.129 1.039 1.037 204.69 $6,207.17 $105.88 0.00 $0.00 $0.00Outpatient Hospital Visits 780.80 965.15 62.80 1.137 1.068 1.039 1.037 953.88 1,113.46 88.51 0.00 0.00 0.00Professional Visits 3,391.82 204.05 57.68 1.137 1.130 1.039 1.037 4,143.69 249.08 86.01 0.00 0.00 0.00Other Medical Services 8,026.91 129.22 86.44 1.137 1.169 1.039 1.037 9,806.24 163.23 133.39 0.00 0.00 0.00Capitation Services 0.23 47.14 0.00 1.137 1.068 1.000 1.000 0.26 50.35 0.00 0.00 0.00 0.00Prescription Drug Prescriptions 9,062.84 44.79 33.83 1.137 1.936 1.077 1.045 11,255.52 100.58 94.34 0.00 0.00 0.00Total $311.81 $508.13 $0.00

After Credibility Projected Period TotalsSection III: Projected Experience: Projected Allowed Experience Claims PMPM (w/applied credibility if applicable) 100.00% 0.00% $508.13 $210,677,031

Paid to Allowed Average Factor in Projection Period 0.649Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $329.53 $136,628,267Projected Risk Adjustments PMPM -0.08 (33,169) Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $329.61 $136,661,436Projected ACA reinsurance recoveries, net of rein prem, PMPM 16.97 7,036,287

Projected Incurred Claims $312.64 $129,625,148

Administrative Expense Load 13.93% 55.04 22,820,252Profit & Risk Load 2.99% 11.81 4,896,626Taxes & Fees 3.92% 15.50 6,424,737Single Risk Pool Gross Premium Avg. Rate, PMPM $394.99 $163,766,763Index Rate for Projection Period $501.54

% increase over Experience Period 52.81%% Increase, annualized: 23.62%

Projected Member Months 414,612

Information Not Releasable to the Public Unless Authorized by Law: This information has not been publically disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Annualized Trend Factors

Page 2 of 2

Product-Plan Data Collection

Company Legal Name: Group Health Cooperative State: WAHIOS Issuer ID: 80473 Market: IndividualEffective Date of Rate Change(s):

Product/Plan Level Calculations

Section I: General Product and Plan InformationProduct e Individual and fam ooperative I&F Core e Individual and Fam ve Individual and Fa tive Individual and F Terminated ProductsProduct ID: 80473WA079 80473WA078 80473WA081 80473WA083 80473WA082 80473WA999Metal: Gold Silver Bronze Bronze Catastrophic Gold Silver Bronze Bronze CatastrophicAV Metal Value 0.812 0.711 0.619 0.602 0.598 0.812 0.711 0.619 0.602 0.000AV Pricing Value 1.219 1.000 0.818 0.786 0.685 1.236 1.014 0.830 0.788 0.000Plan Type: HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO

Plan NameCore3 Gold -15 Core3 Silver -15 Core3 Bronze - 15


Core Basics Plus -15 Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15


Terminated Products

Plan ID (Standard Component ID): 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001 80473WA9999999Exchange Plan? Yes Yes Yes Yes Yes No No No No NoHistorical Rate Increase - Calendar Year - 2 0.00% 0.00% 0.00% 0.00% 0.00% 15.10%Historical Rate Increase - Calendar Year - 1 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%Historical Rate Increase - Calendar Year 0 0.00% 0.00% 0.00% 0.00% 0.00% -99.00%Effective Date of Proposed Rates 1/1/2015 1/1/2015 1/1/2015 1/1/2015 1/1/2015 1/1/2015 1/1/2015 1/1/2015 1/1/2015 1/1/2015Rate Change % (over prior filing) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% -999.00%Cum'tive Rate Change % (over 12 mos prior) -999.00% -999.00% -999.00% -999.00% -999.00% -999.00% -999.00% -999.00% -999.00% -999.00%Proj'd Per Rate Change % (over Exper. Period) #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! -1337.54%Product Threshold Rate Increase % 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

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

Plan ID (Standard Component ID): Total 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001 80473WA9999999Inpatient $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Outpatient $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Professional $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Prescription Drug $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Other $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Capitation $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Administration $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Taxes & Fees $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Risk & Profit Charge $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Total Rate Increase $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Member Cost Share Increase $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Average Current Rate PMPM $391.54 $515.53 $422.80 $346.04 $332.37 $289.62 $522.73 $428.69 $350.85 $333.21 $355.82Projected Member Months 414,612 13,440 118,152 28,560 27,840 636 32,016 35,232 79,368 79,368 0

ction III: Experience Period Information

Plan ID (Standard Component ID): Total 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001 80473WA9999999Average Rate PMPM $258.49 $258.49Member Months 269,820 269,820Total Premium (TP) $69,744,636 $0 $0 $0 $0 $0 $0 $0 $0 $0 $69,744,636

EHB Percent of TP, [see instructions] 98.42% 98.42% state mandated benefits portion of TP that are other than EHB 0.00% 0.00% Other benefits portion of TP 1.58% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 1.58% Total Allowed Claims (TAC) $84,131,932 $84,131,932

EHB Percent of TAC, [see instructions] 98.42% 98.42% state mandated benefits portion of TAC that are other than EHB 0.00% 0.00% Other benefits portion of TAC 1.58% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 1.58%

Allowed Claims which are not the issuer's obligation: $21,239,092 $21,239,092Portion of above payable by HHS's funds on behalf of insured person, in dollars $0 $0 $0 $0 $0 $0Portion of above payable by HHS on behalf of insured person, as % 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.00%

Total Incurred claims, payable with issuer funds $62,892,841 $0 $0 $0 $0 $0 $0 $0 $0 $0 $62,892,841

Net Amt of Rein $0.00 Net Amt of Risk Adj $0.00

Incurred Claims PMPM $233.09 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $233.09Allowed Claims PMPM $311.81 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $311.81EHB portion of Allowed Claims, PMPM $306.89 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $306.89

ction IV: Projected (12 months following effective date)

Plan ID (Standard Component ID): Total 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001 80473WA9999999Plan Adjusted Index Rate $391.54 $515.53 $422.80 $346.04 $332.37 $289.62 $522.73 $428.69 $350.85 $333.21 -$3,198.87Member Months 414,612 13,440 118,152 28,560 27,840 636 32,016 35,232 79,368 79,368 - Total Premium (TP) $162,335,209 $6,928,701 $49,954,504 $9,882,853 $9,253,061 $184,200 $16,735,709 $15,103,724 $27,846,382 $26,446,075 $0

EHB Percent of TP, [see instructions] 98.59% 98.51% 98.47% 98.42% 98.41% 98.36% 98.70% 98.70% 98.70% 98.70% 98.42% state mandated benefits portion of TP that are other than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Other benefits portion of TP 1.41% 1.49% 1.53% 1.58% 1.59% 1.64% 1.30% 1.30% 1.30% 1.30% 1.58% Total Allowed Claims (TAC) $210,677,031 $6,829,275 $60,036,643 $14,512,209 $14,146,355 $323,171 $16,268,308 $17,902,456 $40,329,307 $40,329,307 $0

EHB Percent of TAC, [see instructions] 98.70% 98.70% 98.70% 98.70% 98.70% 98.70% 98.70% 98.70% 98.70% 98.70% 98.42% state mandated benefits portion of TAC that are other than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Other benefits portion of TAC 1.30% 1.30% 1.30% 1.30% 1.30% 1.30% 1.30% 1.30% 1.30% 1.30% 1.58%

Allowed Claims which are not the issuer's obligation $81,051,883 $1,296,686 $20,147,822 $6,620,722 $6,757,758 $176,087 $2,904,794 $5,842,088 $18,093,888 $19,212,037 $0Portion of above payable by HHS's funds on behalf of insured person, in dollars $5,977,575 $5,819,549 $158,026Portion of above payable by HHS on behalf of insured person, as % 7.37% 0.00% 28.88% 2.39% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0!

Total Incurred claims, payable with issuer funds $129,625,148 $5,532,589 $39,888,821 $7,891,487 $7,388,597 $147,084 $13,363,514 $12,060,369 $22,235,419 $21,117,270 $0

Net Amt of Rein $7,036,287 $315,939 $2,199,861 $416,185 $385,626 $7,376 $764,767 $666,930 $1,176,712 $1,102,892 $0 Net Amt of Risk Adj $0

0.00%

alth Cooperative Individual and Family Co 80473WA084

0.00%0.00%0.00%

1/1/2015

th Cooperative Individual and Family Cor 80473WA080

0.00%0.00%0.00%

0.00%

Form # INS-1121 1

Carrier Name Group Health Cooperative

Address 320 Westlake Ave. N., Ste 100Seattle, WA 98109

Carrier Identification Number GROUPHC240JG

Rate Renewal Period: From January 1, 2015 To December 31, 2015

Date Submitted: April 28, 2014

Current community rate $355.07 per month

Proposed community rate $394.99 per month

Percentage change 11.2% %

Portion of carrier's total enrollment affected 6.75 %

Portion of carrier's total premium revenue affected 3.12 %

a) Claims

b) Expenses

c) Contribution to surplus, contingencycharges, or risk chargesd) Investment earnings

e) Total (a + b + c - d)

Dollars Per Month % of Total

$394.99

79.15%

17.86%

3.00%

0.01%

100.00%

INDIVIDUAL FILING SUMMARY(WAC 284-43-945)

Proposed Rate Summary

Components of Proposed Community Rate

Filing Type: Individual S ma ll Group

$312.64

$70.54

$11.85

$0.04

Form # INS-1121 2

From To From To From To1/1/2013 12/31/2013 1/1/2012 12/31/2012 1/1/2011 12/31/2011

Member Months

Earned Premium

Paid Claims

Beginning Claim Reserve

Ending Claim Reserve

Incurred Claims

Expenses

Gain/Loss

Loss Ratio Percentage

1. Trend Factor Summary

Type of Service

Hospital % %

Professional % %

Prescription Drugs % %

Dental % %

Other % %

7.7%

$12,125,113

($3,125,771)

General Information

84.96%

$14,451,713

($6,897,041)

42.9%

($3,232,829)

$8,511,778

Annual TrendAssumed

89.14%

DollarsPortion of Claim

89.17%

$3,893,178

$43,444,438$50,841,670

$59,884,921

($3,630,772)

$5,757,995

$62,012,144

$51,104,076

($3,893,178)

$3,630,772

213,402 152,982

$69,566,816 $48,723,387$59,841,012

$42,227,693

($2,676,433)

Summary of Pooled Experience

SecondPrior Period

FirstPrior Period

Experience

46.2%

10.8%

NA

7.7%

12.6%

NA

NA NA

Period

270,003

Form # INS-1121 3

2. List the effective date and the rate of increase for all rate changes in the past threerate periods.

Date IncreaseJanuary 1, 2014 * NA

July 1, 2012 ** 11.30%February 1, 2012 *** 0.50%

July 1, 2011 **** 0.60%January 1, 2011 ***** 0.90%

* All new plans were introduced for January 2014 and therefore a rate change is not applicable.** This is the increase after benefit changes. The increase before benefit changes is 14.6%.*** Increase for federal mandates.**** This is the increase after benefit changes. The increase before benefit changes is 1.1%.***** Increase for state and federal mandates.

3. Since the previous filing, have any changes been made to the factors or methodology for adjusting base rates?

Geographic AreaFamily SizeAgeWellness ActivitiesOther

4. Attach a table showing the base rate for each plan affected by this filing.See rate sheets.

5. Attach comments or additional information.

6. Preparer's Information

Name: Mark L. Ackerman, ASA, MAAA

Title: Pricing Actuary

Yes Yes Yes Yes Yes

No

No No

No No

1/1/2015 Individual Filing 1 Group Health Cooperative

Group Health Cooperative 320 Westlake Ave. N., Suite 100 Seattle, Washington 98109 www.ghc.org

April 28, 2014 Office of Insurance Commissioner

Health Care Services Division Insurance Building P.O. Box 40255 Olympia, WA 98504-0255

Re: Group Health Cooperative 1/1/2015 Individual Rate Filing Dear Actuary: Enclosed for your review is the 1/1/2015 Group Health Cooperative Individual rate filing. The rates will be in effect for the period 1/1/2015 to 12/31/2015. In this filing, all 2014 plans are terminated and replaced with new 2015 plans. I look forward to discussing this filing with you and your staff. Please call or email me with any questions or comments. Sincerely, Mark Ackerman (electronic signature) Mark L. Ackerman, ASA, MAAA Pricing Actuary Actuarial & Underwriting Group Health Cooperative


Health Care Service Contractor and Health Maintenance Organization Small Group and Individual Community Rate Filing Transmittal Form Carrier: Group Health Cooperative

Line of Business: Individual

Small Group Effective Date: January 1, 2015 Date Submitted: April 28, 2014 Documentation Attached for Each Line of Business

A Description of the Rate-Making Methodology, Experience Data, and Justifications Filing Document Summary WAC 284-43-945 Actuarial Certification Rate Exhibit Illustrative Examples


3

Requirements of WAC 284-43-930 WAC 284-43-930 Contents of individual filings. Under RCW 48.44.022 and 48.46.064 the experience of all individual products must be pooled. Each individual filing must include the following information and documents: 1) An actuarially sound estimate of incurred claims. Experience data, assumptions, and

justifications of the carrier's projected incurred claims must be provided in a manner consistent with the carrier's rate-making methodology and incorporate the following elements:

a) A brief description of the carrier's rate-making methodology, including identification of the

data used and the kinds of assumptions and projections made. The rates were developed utilizing the methodology described by the HHS for the Unified Rate Review Templates as documented in the Part I Unified Rate Review Template Instructions (February 3, 2014) and the Part III Actuarial Memorandum and Certification Instructions (March 20, 2014). This process is explained below. The experience block is the allowed claims incurred in 2013 for individual plans including a small association component and not including group conversion plans. The experience block PMPM (per member per month) claims by broad medical service categories for calendar 2013 was adjusted for expected population morbidity changes, benefit changes relating to covering essential health benefits and removing non-essential health benefits, and expected demographic changes. The medical service categories are inpatient hospital, outpatient hospital, professional, capitation, other medical, and prescription drugs. The adjusted allowed claims PMPM was then trended to the midpoint of the rating period (1/1/2015 to 12/31/2015) using cost per service and utilization trends by the medical service categories in order to arrive at the projected index rate. The following is a description of how the projected index rate was adjusted to arrive at each plan’s average premium rate. Let: a = Projected index rate pmpm

b = Benefit relativity factor c = ACA reinsurance premium paid pmpm d = Administrative expense load as a percent of premium e = Profit and risk load as a percent of premium f = Taxes and fees as a percent of premium g = ACA reinsurance claims recovery as a percent of premium h = ACA risk adjustments (user fee)

Then the given plan’s average rate pmpm = (a * b + c + h) / (One - d - e - f + g). The benefit relativity factor is the actuarial value derived by adjusting the metal level AV to get the AV used in pricing each plan. This factor includes adjustments for demand elasticity, addition of non-essential benefits and a leaner pediatric dental benefit for the HSA plan/removal of pediatric dental for Exchange plans. The plan adjusted index rate is then calculated as the average premium rate with the removal of the overall tobacco user rate load. See Exhibit 18 for more detail on this process. Final rates (“consumer adjusted premium rates”) were derived by taking the adjusted plan index rate pmpm for each plan and calibrating (normalizing) them for the 2015 age and area factors. The 2015 age, area and tobacco use factors were then applied to the calibrated adjusted plan index rates to derive the final rates for each plan. Please see Exhibits 10, 11 and 12. None of the plans are offered on the Exchange.

b) The number of subscribers by family size, or covered persons for the plans included in the filing. These figures must be shown for each month or quarter of the experience period and the prior two periods if not included in previous filings. This data must be presented in aggregate for the plans included in the filing and in aggregate for all of the carrier's plans. See Exhibit 1 showing the exposure, premium and paid claims.


4

c) Earned premium for each month or quarter of the experience period and the prior two periods if not included in previous filings, for the plans included in the filing. See Exhibit 1.

d) An estimate of the adjusted earned premium for each month or quarter of the experience period and prior two periods for the plans included in the filing. See Exhibit 2, Adjusted Earned Premium Calculation. Please note that the 2013 adjusted premium is not calculable because all 2013 plans were eliminated and replaced with new 2014 plans.

e) Claims data for each month or quarter of the experience period and the prior two periods. Examples of claims data are incurred claims, capitation payments, utilization data, unit cost data, and staffing data. The specific data elements included in the filing must be consistent with the carrier's rate-making methodology. See Exhibit 1.

f) Documentation and justification of any adjustments made to the experience data. Incurred allowed claims were adjusted for population morbidity, essential health benefits and demographic changes in determining the projected index rate. The benefit relativity factor includes adjustments for demand elasticity, addition of non-essential benefits and a leaner pediatric dental benefit for the HSA plan. See Exhibit 7 for benefit adjustment calculations. To estimate the change in morbidity we relied on the March 2013 Report sponsored by the Society of Actuaries: Cost of the Future Newly Insured under the Affordable Care Act (ACA). The total population morbidity factor is 1.137. Please see Exhibit 17. The demographic change factor was determined by taking the composite ACA age factor, Group Health area factor and Group Health tobacco use status factor for the March 2014 GHC individual plan population and dividing by the composite factor for the 2013 GHC individual plan population.

g) Documentation and justification of the factors and methods used to forecast incurred claims. See Exhibit 3 and Exhibit 4.

2) An actuarially sound estimate of prudently incurred expenses. Experience data, assumptions, and justifications must be provided by the carrier as follows:

a) A breakdown of the carrier's expenses allocated or assigned to the plans included in the

filing for the experience period or for the period corresponding to the most recent "annual statement"; i) An expense breakdown at least as detailed as the annual statement schedule

"Underwriting and Investment Exhibit, Part 3, Analysis of Expenses" as revised from time to time; The 2013 Underwriting and Investment Exhibit, Part 3 is included as Exhibit 13.

ii) The allocation and assignment methodology used in (a)(i) of this subsection may be based on readily available data and easily applied calculations; See response to i).

b) Identification of any extraordinary experience period expenses; and There were no known extraordinary administrative expenses.

c) Documentation and justification of the assignment or allocation of expenses to the plans included in the filing; and The administrative expense information was taken from work used to build the statutory administrative expense. See Exhibit 8 for administrative cost information.

d) Documentation and justification of forecasted changes in expenses. Fixed pmpm operating expenses are expected to increase by 3% per annum from the calendar 2013 experience period level (See Exhibit 8 and Exhibit 16). Broker commissions have been adjusted for a reduced percentage level effective from 2013 levels (see Exhibit 9). Below is a table of taxes and fees built into the 2015 rates:


5

ACA Federal Carrier Fee [Percent of Premium] (Section 9010 of the ACA)

1.00%

ACA Comparative Effectiveness or PCORI $PMPY (Section 4375 of the ACA)

$2.28

Washington State Premium Tax - [Percent of Premium] 2% Washington State High Risk Pool Assessment $PMPM $1.19 ACA Reinsurance Fee PMPM (HHS Notice of Benefit and Payment Parameters, 3/11/2014)

$3.67

Risk Adjustment Administration Fee $PMPY (HHS Notice of Benefit and Payment Parameters, 3/11/2014)

$0.96

Exchange Fees PMPM $1.91 Washington State OIC Surcharge – [Percent of Premium] 0.093%

See Exhibit 6 for the calculation of the ACA Federal Carrier Fee. 3) An actuarially sound provision for contribution to surplus, contingency charges, or risk

charges. Assumptions and justifications must be provided by the carrier as follows: a) The methodology, justification, and calculations used to determine the contribution to

surplus, contingency charges, or risk charges included in the proposed base rates; and The rates developed in this filing are expected to produce a 2% contribution to surplus. There is also a 1% overall risk and contingency charge (see Exhibit 5).

b) The carrier's net worth or reserves and unassigned surplus at the beginning and end of the experience period. (Note: Taken from statutory financial statements, page 3, line titled “Total Capital and Surplus”)

Date GHC Surplus 12/31/2010 $605,780,137 12/31/2011 $482,474,600 12/31/2012 $431,260,181 12/31/2013 $803,526,658

4) An actuarially sound estimate of forecasted investment earnings on assets related to claim

reserves or other similar liabilities. The carrier must include documentation and justification of forecasted investment earnings identified in dollars, and as a percentage of total premiums and the amount credited to the plans included in the filing. See section “Investment Income Information”.

5) Adjustment of the base rate. Experience data, assumptions, justifications, and methodology

descriptions must be provided and must include:

a) Justifications for adjustments to the base rate, supported by data if appropriate, attributable to geographic region, age, family size and wellness activities; The Area factors were developed based on the main driver of Group Health contractual cost differences by area which is inpatient hospital costs. We used case mix adjusted allowed inpatient claims per day for our entire commercial block of business for the experience period October 2011 to September 2012, paid through Dec 2012 excluding selected specialized facilities that typically serve members from all geographic regions. We calculated the ratio of adjusted allowed costs per day to the Index Area 1 adjusted allowed cost per day to get the inpatient specific relative costs. We weighted these numbers at 22% of allowed claims attributable to Inpatient Claims and the other at 78% of allowed claims at a 1.0 relative cost factor to arrive at the final proposed area factors. The final area factors comply with WAC 284-170-250 regulations. Area 1 – King County is the Index area at 1.0 and the ratio of the highest to lowest area factor is 1.086 which is less than the 1.15 permitted.


6

We are applying a 1.2 premium factor for tobacco use for age bands 21 and over. This is the same as our current factor applied for tobacco use. A paid claims analysis of current tobacco versus non-tobacco users supports this factor as reasonable and appropriate. Group Health Cooperative Individual Plans

Premium Paid Claims Paid Loss Ratio

Non-Tobacco User $49,938,963 $39,034,291 78.2% Tobacco User $ 4,437,809 $ 5,505,326 124.1%

b) Justifications, supported by data if appropriate, of any other factors or circumstances used to adjust the base rates; and There are no other adjustments to the base rates.

c) Description of the methodology used to adjust the base rate to obtain the premium rate for a specific individual or group, which is detailed enough to allow the commissioner to replicate the calculation of premium rates if given the necessary data. All renewing applicant ages in 2015 are determined as of January 1, 2015. New applicant ages are determined as of the first of the month that coverage is effective. The rating area is determined by the primary subscriber’s residence. A designation of “tobacco user” is given if the applicant is age 21 or over and has used tobacco or nicotine products regularly within the last 6 months where regular tobacco use is defined as 4 or more times per week, excluding religious or ceremonial use. Once the applicant’s age, area and tobacco use status are determined, the appropriate rate can be looked up in the Rate Schedule. Please note that no more than the three oldest covered children under 21 are charged premiums.

6) Actuarial certification. Certification by an actuary as required by RCW 48.44.023(3) and

48.46.066(3). See attached Actuarial Certification.

7) The requirements of subsections (1) through (6) of this section may be waived or modified

upon the finding by the commissioner that a plan contains or involves unique provisions or circumstances and that the requirements represent an extraordinary administrative burden on the carrier. No waiver is being requested by Group Health Cooperative

Rating Area

Case Mix Adjusted

Allowed per Day

Case Mix Adjusted

Allowed per day relative

to Area 1

Final Area

Factor

Ratio Highest to

Lowest (Area 2 to

Area 4) Area 1 $ 3,577 1.000 1.000 Area 2 $ 4,179 1.168 1.037 1.085 Area 4 $ 2,857 0.799 0.956 Area 5 $ 3,634 1.016 1.004


7

(WAC 284-43-930.4)

Investment Income Information GrandTotal

A $10,006,081B $129,625,148C 79.15%D $163,766,763E $4,896,626F $12,454,394G 0.12%H $14,945I 0.01%

Net Investment Rate *Net Investment Income = F. x G.Investment Income Offset = H. / D.

Anticipated Contribution to SurplusClaim Reserve + ½ Contribution to Surplus

6/30/2015 Estimated Claim Reserve1/1/2015 to 12/31/2015 Estimated Incurred ClaimsAnticipated Incurred Loss RatioAnticipated Premium

* Uses a T-bill rate of 0.12%.

(WAC 284-43-930.3a) Development of Target Contribution to Surplus

The pricing was developed with a target contribution to surplus of 2%. This level of contribution to surplus is necessary because of individual GHC’s marginal financial performance.


Actuarial Certification I, Mark L. Ackerman, am a member of the American Academy of Actuaries. I certify that the benefits are reasonable in relation to the amount charged. I hereby certify that to the best of my knowledge and judgment, the 1/1/2015 rate filing for the Group Health Cooperative individual product line is in compliance with the applicable laws and regulations of the State of Washington. Signed: __Mark Ackerman _(electronic signature)_________ Mark L. Ackerman, ASA, MAAA Title: Pricing Actuary Actuarial & Underwriting Group Health Cooperative Date: April 28, 2014


Individual Non-grandfathered Health Plan (Pool) Rate Filing Checklist I. Market Rule (Plans Required to be Sold) A. Inside the Exchange:

1. You must offer at least one qualified health plan (QHP) in the silver coverage level and at least one QHP in the gold coverage level. See 45 CFR § 156.200 (c). We offer one silver and one gold coverage level QHP. 2. A health benefit plan meeting the definition of catastrophic plan

may only be sold through the Exchange. See RCW 48.43.700 (2).

We are offering only one catastrophic plan inside, but not outside,

the Exchange.

B. Outside the Exchange 3. If you offer a bronze plan, you must offer silver and gold plans. See RCW 48.43.700 (1).

We offer bronze, silver and gold plans outside the Exchange.

II. Documentation Required 1. Parts I, II, and III of HHS Forms. (Requirements per RCW

48.02.120 (5) and 45 CFR §154.215).

Parts I, II, and III of HHS Forms are attached.

2. WAC 284-43-945.

WAC 284-43-945 is attached.

3. For HCSCs and HMOs, the requirements under WAC 284-43-930.

WAC 284-43-930 is attached.

4. A description of benefit components used for the development of the Metal Plan and its Actuarial Value (AV). A description of benefit components used in the development of the

metal plans and their AVs are attached.

5. If HHS AV Calculator is used, a one-page printout in pdf format showing “Calculation Successful.”


Below are screen shots of the HHS AV Calculator used to develop the metal benefit plans.

6. If HHS AV Calculator is not used, provide all required actuarial certification, documentation, and justification under 45 CFR §156.135.

The HHS AV Calculator was solely used – thus no additional certification, documentation or justification is required.

7. A description of the additional non-essential health benefits used for

pricing and rate development.

The additional non-essential health benefit used for pricing and rate development was adult vision exam coverage at the same benefit level as a primary care office visit for both exchange and non-exchange products. See Exhibit 23.

8. Documentation and justification of all allowable rating factors under 45 CFR §147.102, including Tobacco Use factor and Geographic Rating Area Factor.

We are using the prescribed HHS standard age factors. The Geographic Rating Area Factors and Tobacco Use factor are described in the Response to item 5a in the WAC 284-43-930

9. An illustrative example and rule of how the rating factors are

applied. Provide a statement that rates are charged to no more than the three oldest covered children under 21 for a family coverage. For an enrollee age 30, Gold Non-exchange plan (Core3 Gold-15)

Tobacco User in Thurston County (Area 2) effective February 1, 2015:

Monthly Premium = $427.44, obtained by looking up age 30 and area 2 for the Core3 Gold-15 plan in the tobacco user schedule. All renewing applicant ages in 2015 are determined as of January 1, 2015. New applicant ages are determined as of the first of the month that coverage is effective. The rating area is determined by the primary subscriber’s residence. A designation of “tobacco user” is given if the applicant is age 21 or over and has used tobacco or nicotine products regularly within the last 6 months where regular tobacco use is defined as 4 or more times per week, excluding


religious or ceremonial use. The enrollee’s age band doesn’t change until the next plan rate renewal (January 1, 2016).

We certify that no more than the three oldest covered children under 21 are charged premiums.

10. For each plan, explain in detail and provide justification whether the

premium rate for the plan varies from the market wide index rate for the following factors: (a) The Actuarial Value (AV) and cost sharing design of the plan. See tables below and explanation of premium development in Item 1a of the WAC 284-43-930.

Product:



Bronze Exchange





ExchangeItem Product ID: 80473WA079 80473WA078 80473WA081

Metal: Gold Silver Bronze Bronze Catastrophica Market Adjusted Index Rate PMPM $486.56 $486.56 $486.56 $486.56 $486.56b Index Rate Allowed Claims PMPM $501.54 $501.54 $501.54 $501.54 $501.54c Starting AV Value (AV Metal Value) 0.812 0.711 0.619 0.602 0.598d Catastrophic Plan Eligibility Impact 1.000 1.000 1.000 1.000 0.880e Demand Elasticity Adj. 1.070 1.000 0.937 0.925 0.922f Non-EHB Benefits 1.013 1.013 1.013 1.013 1.013

gAdjustment to Pediatric Dental Benefit (Remove from Exchange Plans, Leaner Benefit for HSA Direct Plan) 0.986 0.986 0.986 0.986 0.986

h Benefit Relativity Factor (= c x d x e x f x g) 0.867 0.710 0.580 0.557 0.484i Paid Claims (= b x h) $435.08 $356.14 $290.80 $279.17 $242.78j Non-EHB Benefits Claims PMPM $5.64 $4.62 $3.77 $3.62 $3.15k Reinsurance Premium PMPM $3.67 $3.67 $3.67 $3.67 $3.67l Total Admin, Taxes & Fees, Profit, R&C % of Premium 20.8% 20.8% 20.8% 20.8% 20.8%

m Reinsurance Recovery as a % of Premium 5.2% 5.2% 5.2% 5.2% 5.2%n Risk Adjustments (User Fee) $0.08 $0.08 $0.08 $0.08 $0.08o 2015 Average Premium Rate PMPM [= (i + k + n) / (1 - l + m)] $520.07 $426.53 $349.09 $335.30 $292.18

p Composite Age Factor / Composite Age-Tobacco Use Factor 0.991 0.991 0.991 0.991 0.991q URRT Plan Adjusted Index Rate $515.53 $422.80 $346.04 $332.37 $289.62r URRT AV Pricing Value (= q / Exchange Silver q value) 1.219 1.000 0.818 0.786 0.685

Plan Name: Core3 Gold -15 Core3 Silver -15 Core3 Bronze - 15Core Bronze

H.S.A. -15 Core Basics Plus -15Plan ID : 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001


80473WA080


Product:





Item Product ID: 80473WA083 80473WA082Metal: Gold Silver Bronze Bronze

a Market Adjusted Index Rate PMPM $486.56 $486.56 $486.56 $486.56b Index Rate Allowed Claims PMPM $501.54 $501.54 $501.54 $501.54c Starting AV Value (AV Metal Value) 0.812 0.711 0.619 0.602d Catastrophic Plan Eligibility Impact 1.000 1.000 1.000 1.000e Demand Elasticity Adj. 1.070 1.000 0.937 0.925f Non-EHB Benefits 1.013 1.013 1.013 1.013

gAdjustment to Pediatric Dental Benefit (Remove from Exchange Plans, Leaner Benefit for HSA Direct Plan) 1.000 1.000 1.000 0.989

h Benefit Relativity Factor (= c x d x e x f x g) 0.880 0.720 0.588 0.558i Paid Claims (= b x h) $441.21 $361.16 $294.90 $279.88j Non-EHB Benefits Claims PMPM $5.72 $4.68 $3.82 $3.63k Reinsurance Premium PMPM $3.67 $3.67 $3.67 $3.67l Total Admin, Taxes & Fees, Profit, R&C % of Premium 20.8% 20.8% 20.8% 20.8%

m Reinsurance Recovery as a % of Premium 5.2% 5.2% 5.2% 5.2%n Risk Adjustments (User Fee) $0.08 $0.08 $0.08 $0.08o 2015 Average Premium Rate PMPM [= (i + k + n) / (1 - l + m)] $527.34 $432.47 $353.95 $336.15

p Composite Age Factor / Composite Age-Tobacco Use Factor 0.991 0.991 0.991 0.991q URRT Plan Adjusted Index Rate $522.73 $428.69 $350.85 $333.21r URRT AV Pricing Value (= q / Exchange Silver q value) 1.236 1.014 0.830 0.788

Plan Name: Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15Core Bronze

H.S.A. -15Plan ID : 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001


80473WA084

(b) The plan’s provider network and delivery system

characteristics, and utilization management practices. No Variation. (c) Plan benefits in addition to the essential health benefits. See above tables and explanation of premium development in section 1a of the WAC 284-43-930. (d) Administrative costs, excluding Exchange user fees. See explanation of premium development in Item 1a of the WAC 284-43-930. (e) With respect to catastrophic plans, the expected impact of the specific eligibility categories for those plans. To estimate a factor that reflects the difference in anticipated demographics and morbidity of the catastrophic population we assumed that the population likely to enroll in the catastrophic plan would reflect the individual risk pool prior to ACA reforms therefore we set the catastrophic plan adjustment to remove the overall population morbidity adjustment of 1.1367 – which results in a plan level adjustment of 1/1.1367 = 0.880.

11. For each plan, explain in detail whether the pediatric dental

benefits are included as an embedded set of benefits, or through a


combination of a health benefit plan and a stand-alone dental plan that includes pediatric dental benefits certified as a qualified dental plan. Pediatric dental benefits are included as an embedded set of benefits for each of the non-exchange Group Health Cooperative Individual plans offered. For exchange GHC individual plans, pediatric dental must be purchased as a stand-alone dental plan.


Index of Exhibits Exhibit 1 Exposure, Premium and Paid Claims

Exhibit 2 Adjusted Earned Premium

Exhibit 3 Claims Trend - Historical

Exhibit 4 Final Pricing Trend

Exhibit 5 Risk and Contingency Charge

Exhibit 6 ACA Carrier Fee Calculation

Exhibit 7 Benefit Adjustments

Exhibit 8 Administration Cost Calculation

Exhibit 9 Commission Percentage Calculation

Exhibit 10 Rate Adjustments

Exhibit 11 Final Rates

Exhibit 12 Composite Rate Check

Exhibit 13 2013 Underwriting and Investment Exhibit Part 3

Exhibit 14 Paid to Allowed Ratios


Exhibit 15 URRT Administrative Cost,Taxes & Fees, Profit & Risk Detail

Exhibit 16 Administrative Cost Trend and Variable Component

Exhibit 17 Population Morbidity

Exhibit 18 Plan Adjusted Index Rate Calculation

Exhibit 19 Geographic Area Factor Build Up

Exhibit 20 Projected MLR

Exhibit 21 Reinsurance Calculation

Exhibit 22 WSHIP Assessment

Exhibit 23 Non-Essential Health Benefit Detail

Exhibit 24 Market Adjusted Index Rate Calculation

Exhibit 25 Rate Increase Calculation

DateTotal

ExposureEarned

Premium

Internal Delivery System *

Hospital Inpatient

Hospital Outpatient

Other Services Pharmacy

Primary Care

Specialty Care

Total Paid Claims

Jan-11 11,441 $3,909,186 $729,056 $1,007,981 $615,373 $304,053 $532,439 $44,776 $330,953 $3,564,631Feb-11 11,342 $3,876,060 $740,152 $1,033,668 $489,212 $259,105 $482,549 $30,039 $204,029 $3,238,754Mar-11 11,263 $3,802,038 $748,486 $1,559,377 $438,749 $267,095 $523,033 $42,443 $242,561 $3,821,744Apr-11 11,194 $3,823,281 $731,822 $570,205 $474,608 $327,261 $481,426 $44,648 $240,894 $2,870,865

May-11 11,168 $3,817,053 $845,934 $568,220 $562,907 $300,204 $575,438 $41,486 $253,643 $3,147,833Jun-11 11,120 $3,717,608 $845,453 $925,685 $552,405 $342,620 $527,446 $52,480 $324,246 $3,570,335Jul-11 13,182 $4,510,983 $860,245 $881,017 $413,634 $299,766 $535,830 $47,479 $386,759 $3,424,732

Aug-11 13,489 $3,968,448 $853,546 $493,828 $710,805 $372,582 $566,180 $47,113 $400,838 $3,444,893Sep-11 13,861 $4,191,208 $957,852 $1,451,676 $620,554 $333,810 $550,097 $56,309 $379,324 $4,349,622Oct-11 14,483 $4,298,770 $1,152,529 $815,026 $530,130 $354,005 $526,159 $61,806 $303,217 $3,742,872Nov-11 15,033 $4,400,195 $946,059 $721,705 $709,732 $323,657 $544,675 $78,673 $315,547 $3,640,047Dec-11 15,406 $4,408,556 $1,082,661 $487,008 $520,700 $343,150 $570,192 $65,708 $341,946 $3,411,365Jan-12 15,788 $4,432,247 $1,099,789 $830,373 $695,141 $390,780 $644,891 $62,031 $228,835 $3,951,839Feb-12 16,101 $4,535,505 $1,020,793 $704,495 $619,616 $330,560 $511,731 $70,081 $327,003 $3,584,279Mar-12 16,373 $4,546,239 $1,058,752 $1,074,678 $845,295 $412,754 $592,682 $69,997 $382,198 $4,436,357Apr-12 16,797 $4,536,996 $1,038,341 $852,913 $744,914 $338,507 $577,497 $69,566 $324,842 $3,946,580

May-12 17,076 $4,659,952 $1,066,984 $557,562 $567,014 $387,409 $622,535 $74,417 $328,859 $3,604,780Jun-12 17,208 $4,586,258 $1,102,483 $2,042,201 $733,312 $340,040 $591,789 $85,426 $372,108 $5,267,359Jul-12 18,264 $5,681,301 $1,147,361 $960,057 $612,332 $453,766 $555,863 $79,538 $315,331 $4,124,248

Aug-12 18,576 $5,188,128 $947,984 $1,127,985 $834,922 $416,270 $576,987 $91,887 $313,084 $4,309,118Sep-12 18,685 $5,380,069 $1,242,992 $620,810 $704,828 $426,587 $511,049 $75,015 $252,889 $3,834,169Oct-12 19,056 $5,415,521 $1,183,868 $1,048,876 $782,385 $458,913 $710,061 $116,120 $419,627 $4,719,851Nov-12 19,504 $5,416,291 $1,318,002 $804,276 $786,406 $425,729 $611,814 $103,384 $429,592 $4,479,203Dec-12 19,974 $5,462,504 $1,333,253 $1,256,660 $754,418 $365,911 $671,041 $104,525 $360,485 $4,846,293Jan-13 20,382 $5,580,190 $1,336,206 $697,512 $812,003 $574,338 $610,486 $114,737 $358,470 $4,503,751Feb-13 20,911 $5,690,554 $1,032,978 $1,365,975 $515,528 $390,852 $495,506 $104,161 $317,488 $4,222,487Mar-13 21,341 $5,704,641 $1,418,540 $1,368,356 $727,112 $459,843 $589,578 $103,100 $474,235 $5,140,763Apr-13 22,174 $5,812,239 $1,176,365 $1,139,062 $899,208 $376,795 $619,392 $88,833 $332,000 $4,631,656

May-13 22,772 $5,868,966 $1,334,621 $707,746 $958,652 $449,099 $565,838 $121,343 $400,495 $4,537,794Jun-13 23,120 $5,923,269 $1,307,755 $755,047 $641,022 $453,179 $595,732 $96,953 $441,634 $4,291,322Jul-13 23,347 $6,014,743 $1,360,524 $1,373,670 $839,894 $528,007 $647,877 $117,169 $513,897 $5,381,038

Aug-13 23,518 $5,914,703 $1,293,819 $1,007,488 $1,182,461 $520,890 $596,392 $110,651 $478,601 $5,190,302Sep-13 23,569 $5,891,441 $1,474,609 $926,579 $730,040 $506,864 $646,610 $112,863 $418,413 $4,815,978Oct-13 23,505 $5,911,594 $1,658,586 $2,036,111 $893,198 $605,460 $668,061 $145,424 $562,756 $6,569,596Nov-13 23,265 $5,825,641 $1,493,697 $922,803 $895,065 $478,696 $587,377 $143,082 $475,341 $4,996,060Dec-13 22,099 $5,428,833 $1,721,422 $1,131,471 $740,446 $614,830 $757,673 $128,712 $509,621 $5,604,175

* Internal Delivery System has primary care and specialty care claims for Group Health owned and operated facilities.Note: Includes Group Conversion.


Paid Claims

GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 1 - EXPOSURE, PREMIUM AND PAID CLAIMS

Welcome 1000 Welcome 2000 Welcome 3500 Compass 500 Compass 1840 HSA 1840 HSA 2000 HSA 2500 High Option 500 1000 Group Conversion TotalEarned Earned Earned Earned Earned Earned Earned Earned Earned Earned Earned Earned Earned

Month Premium Premium Premium Premium Premium Premium Premium Premium Premium Premium Premium Premium PremiumJanuary-11 $521,722 $225,013 $143,931 $503,009 $652,845 $68,199 $94,108 $952,001 $554,417 $175,405 $18,535 $3,909,186

February-11 $505,440 $213,034 $147,413 $493,383 $644,208 $67,363 $95,239 $973,879 $539,910 $177,333 $18,858 $3,876,060March-11 $516,133 $217,611 $144,789 $484,997 $629,813 $65,154 $93,120 $920,110 $535,834 $175,004 $19,473 $3,802,038

April-11 $520,907 $224,069 $145,901 $471,477 $616,713 $63,890 $89,873 $965,346 $541,444 $165,725 $17,936 $3,823,281May-11 $531,968 $233,092 $143,780 $470,152 $616,565 $61,447 $90,569 $950,526 $533,630 $167,819 $17,505 $3,817,053

June-11 $538,747 $234,035 $143,619 $454,564 $595,575 $62,002 -$614 $90,342 $894,971 $522,336 $164,296 $17,736 $3,717,608July-11 $638,387 $373,281 $373,062 $457,027 $606,476 $383 $419,078 $660 $937,529 $521,322 $164,436 $19,342 $4,510,983

August-11 $570,878 $295,832 $247,465 $417,080 $576,495 -$543 $261,871 -$660 $900,758 $514,862 $161,286 $23,125 $3,968,448September-11 $632,129 $345,902 $304,612 $440,192 $569,197 $314 $337,786 $886,591 $506,298 $154,273 $13,912 $4,191,208

October-11 $670,633 $362,516 $346,713 $421,545 $567,649 $387,685 $858,891 $506,558 $160,543 $16,037 $4,298,770November-11 $691,225 $380,149 $378,355 $418,193 $563,083 -$1,986 $404,964 $892,512 $500,839 $153,141 $19,721 $4,400,195December-11 $718,875 $395,935 $405,064 $406,559 $551,652 $1,986 $427,653 $853,780 $486,774 $149,155 $11,124 $4,408,556

January-12 $729,491 $417,793 $423,674 $390,880 $532,336 $465,549 $810,873 $484,327 $151,167 $26,158 $4,432,247February-12 $767,008 $435,145 $447,045 $398,316 $528,823 $482,125 $836,511 $477,174 $149,128 $14,229 $4,535,505

March-12 $784,393 $440,324 $451,956 $389,281 $523,592 $501,830 $822,556 $471,674 $144,225 $16,408 $4,546,239April-12 $792,778 $458,668 $467,466 $375,395 $510,349 $514,129 $803,793 $456,060 $143,276 $15,082 $4,536,996May-12 $858,982 $473,174 $481,793 $373,152 $502,811 $557,484 $798,521 $457,875 $139,573 $16,587 $4,659,952

June-12 $847,940 $477,944 $496,826 $360,573 $497,893 $543,884 $761,482 $439,536 $144,423 $15,757 $4,586,258July-12 $1,349,621 $667,595 $754,558 -$3,003 -$19 $1,344,417 $886,931 $507,723 $156,733 $16,745 $5,681,301

August-12 $1,213,979 $625,299 $705,634 -$1,203 $1,176,754 $829,208 $468,569 $150,533 $19,354 $5,188,128September-12 $1,265,045 $651,709 $738,403 $630 $1,651 $1,241,879 $845,494 $465,560 $154,421 $15,277 $5,380,069

October-12 $1,249,624 $693,069 $778,216 -$184 $1,247,781 $807,708 $476,598 $145,069 $17,639 $5,415,521November-12 $1,287,485 $697,461 $800,407 $750 $1,264,087 $749,674 $456,994 $142,737 $16,697 $5,416,291December-12 $1,251,380 $718,525 $828,102 $1,260,680 $784,495 $457,638 $144,930 $16,755 $5,462,504

January-13 $1,261,546 $774,939 $897,782 $1,305,515 $736,936 $447,684 $139,742 $16,045 $5,580,190February-13 $1,274,069 $793,505 $931,222 $1,327,316 $771,206 $431,871 $145,388 $15,977 $5,690,554

March-13 $1,253,883 $825,224 $946,628 $1,332,482 $759,102 $431,568 $140,308 $15,446 $5,704,641April-13 $1,276,191 $856,057 $1,012,761 $1,364,743 $729,710 $420,572 $136,270 $15,934 $5,812,239May-13 $1,286,269 $888,853 $1,056,441 $1,359,931 $710,227 $414,107 $135,382 $17,756 $5,868,966

June-13 $1,282,102 $908,956 $1,067,331 $1,377,867 $717,308 $413,434 $140,534 $15,736 $5,923,269July-13 $1,294,252 $926,774 $1,080,198 $1,387,197 $756,939 $417,641 $134,871 $16,871 $6,014,743

August-13 $1,276,781 $928,296 $1,102,002 $1,386,903 $678,388 $399,752 $128,099 $14,482 $5,914,703September-13 $1,262,674 $935,547 $1,110,000 $1,378,775 $671,435 $390,812 $126,696 $15,503 $5,891,441

October-13 $1,288,499 $934,277 $1,123,751 $1,360,241 $671,818 $389,480 $127,482 $16,047 $5,911,594November-13 $1,260,829 $916,057 $1,114,703 $1,332,640 $702,191 $360,400 $122,894 $15,929 $5,825,641December-13 $1,176,430 $852,256 $1,042,361 $1,243,714 $623,455 $354,880 $119,706 $16,030 $5,428,833

Welcome 1000 Welcome 2000 Welcome 3500 Compass 500 Compass 1840 HSA 1840 HSA 2000 HSA 2500 High Option 500 1000 Group ConversionRate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate

Effective Date Increase Increase Increase Increase Increase Increase Increase Increase Increase Increase Increase IncreaseJuly-11 -2.0% -2.9% -1.1% 1.1% 1.1% 1.1% new product 1.1% 1.1% 1.1% 1.1% 1.1%

February-12 3.7% 0.0% 0.0% 0.0% -0.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%July-12 11.7% 14.3% 14.1% 0.0% 0.0% 14.1% 14.1% 14.1% 14.6% 14.6% 14.6% 17.0%

January-14 * All New Products All New Products All New Products All New Products All New Products All New Products All New Products All New Products All New Products All New Products All New Products All New Products

Welcome 1000 Welcome 2000 Welcome 3500 Compass 500 Compass 1840 HSA 1840 HSA 2000 HSA 2500 High Option 500 1000 Group Conversion TotalAdjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned Adjusted Earned

Month Premium Premium Premium Premium Premium Premium Premium Premium Premium Premium Premium Premium PremiumJan-2011 to Dec-2013 Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable Not Calculable

* Since all 2013 products were eliminated as of 1-1-2014 and replaced with new products, adjusted earned premium on 2013 products is not calculable.

Note: Compass 500 and Compass 1840 Plans Eliminated as of 7/1/2012.


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 2 - ADJUSTED EARNED PREMIUM CALCULATION

Incurred Members Inpatient Outpatient Professional Other Capitation RxInpatient

DaysOutpatient

VisitsProfessional

VisitsOther

ServicesCapitation Services Rx Scripts

Jan-11 167,504 $12,380,861 $9,758,933 $10,495,353 $15,821,981 $335,607 $8,646,455 3,606 11,543 66,574 130,043 3,787 217,786 Feb-11 167,498 $10,245,798 $9,403,139 $9,827,675 $14,216,644 $322,391 $7,997,304 2,921 10,602 62,711 116,503 4,022 199,576 Mar-11 167,486 $10,761,565 $11,146,856 $12,013,497 $17,420,155 $346,178 $9,299,721 2,917 12,906 75,506 143,957 4,407 233,294 Apr-11 167,492 $11,639,755 $9,818,496 $10,773,232 $16,112,852 $305,390 $8,399,761 3,064 11,461 67,096 130,654 4,106 211,837

May-11 167,479 $13,752,952 $10,515,299 $11,083,035 $16,692,288 $318,879 $8,978,354 3,389 11,730 68,425 131,598 4,301 222,298 Jun-11 167,492 $9,657,110 $11,720,249 $11,233,943 $17,214,679 $329,095 $9,272,831 3,059 12,215 69,864 134,395 4,579 222,320 Jul-11 167,515 $11,912,685 $11,391,481 $10,178,123 $15,238,617 $275,917 $8,600,282 3,171 11,559 62,019 122,096 3,682 211,586

Aug-11 167,514 $11,289,013 $11,982,216 $11,855,044 $17,906,592 $307,766 $9,436,288 3,184 13,017 72,144 142,189 4,087 222,421 Sep-11 167,532 $10,305,244 $11,327,924 $10,625,062 $16,980,165 $312,848 $8,970,447 3,277 11,925 65,134 144,133 4,430 213,436 Oct-11 167,479 $10,539,016 $11,510,729 $10,962,204 $17,775,217 $289,331 $8,602,600 3,273 11,933 67,161 154,381 4,172 214,475 Nov-11 167,473 $12,101,139 $12,074,020 $10,956,799 $17,421,726 $291,311 $8,400,859 3,115 12,222 67,108 143,172 4,305 218,070 Dec-11 167,504 $12,898,240 $11,550,017 $10,933,978 $18,540,070 $302,262 $8,849,400 3,548 12,009 66,193 141,152 4,497 224,396 Jan-12 167,465 $10,129,267 $12,414,040 $10,499,388 $16,629,738 $187,642 $8,787,852 3,081 11,571 63,372 129,873 2,388 225,354 Feb-12 167,445 $13,429,205 $12,100,054 $11,631,754 $17,213,464 $294,623 $8,549,236 4,133 12,272 68,205 133,828 3,986 215,855 Mar-12 167,449 $13,125,148 $13,558,403 $12,444,587 $18,653,217 $371,383 $9,393,134 3,437 13,223 72,852 145,078 5,715 231,285 Apr-12 167,456 $10,611,737 $12,043,108 $11,801,287 $17,826,837 $241,883 $8,832,707 2,890 12,372 68,144 137,103 3,713 220,882

May-12 167,450 $12,168,015 $13,275,804 $12,465,600 $19,058,668 $290,023 $9,355,770 3,121 12,990 71,796 148,541 4,182 231,488 Jun-12 167,439 $11,379,596 $12,363,263 $11,838,824 $18,192,875 $281,623 $8,791,026 3,104 12,226 66,609 141,521 3,913 218,911 Jul-12 167,443 $11,756,561 $13,108,964 $11,920,574 $18,091,571 $239,581 $8,834,720 3,135 12,377 66,929 138,055 3,530 225,483

Aug-12 167,454 $14,346,961 $12,818,680 $13,078,454 $19,884,267 $287,397 $9,380,914 3,522 13,060 73,004 149,876 4,204 231,062 Sep-12 167,444 $13,570,926 $11,475,989 $11,249,070 $17,123,094 $242,996 $8,479,203 3,430 11,575 62,493 138,733 3,333 211,191 Oct-12 167,421 $11,553,741 $12,857,087 $12,746,501 $20,001,795 $293,470 $9,424,729 3,460 12,946 72,684 170,141 4,525 236,289 Nov-12 167,421 $13,833,924 $12,095,555 $11,706,484 $18,943,381 $278,888 $9,268,107 3,128 12,024 66,551 146,627 3,915 227,082 Dec-12 167,432 $16,232,014 $12,644,340 $11,497,051 $18,249,420 $244,429 $9,089,442 3,930 11,737 63,882 136,252 3,600 227,407 Jan-13 167,169 $10,891,879 $13,959,107 $12,713,304 $19,136,331 $272,171 $9,771,488 3,220 12,982 73,162 152,230 3,844 244,577 Feb-13 167,138 $11,274,490 $12,214,546 $11,582,215 $17,545,448 $280,016 $8,684,304 3,389 11,239 64,576 130,602 3,748 216,910 Mar-13 167,117 $15,739,530 $12,410,875 $13,328,775 $18,855,879 $266,300 $9,547,136 3,736 12,094 70,337 142,423 3,552 235,071 Apr-13 167,108 $17,636,427 $13,196,780 $13,000,414 $19,312,366 $250,452 $9,536,216 4,251 12,159 71,258 143,442 3,359 235,138

May-13 167,119 $18,291,607 $13,486,370 $13,466,806 $19,953,193 $334,918 $10,183,600 4,793 12,605 72,256 146,658 4,606 239,134 Jun-13 167,138 $13,422,305 $12,415,188 $12,592,234 $18,595,660 $253,334 $9,717,923 3,654 11,753 66,161 136,401 3,352 225,352 Jul-13 167,092 $14,357,766 $14,149,225 $12,975,235 $20,050,011 $291,575 $10,171,276 3,919 12,771 70,743 147,700 3,928 235,771

Aug-13 167,105 $14,955,204 $13,837,031 $13,391,956 $20,778,041 $292,973 $10,478,001 4,091 13,331 72,101 154,902 3,758 235,486 Sep-13 167,111 $13,693,688 $13,340,162 $12,488,697 $19,376,051 $161,761 $10,038,709 3,746 12,334 66,260 154,794 3,076 226,650 Oct-13 167,089 $14,914,822 $15,007,803 $13,970,855 $22,516,043 $340,522 $11,015,669 4,464 13,983 74,797 186,463 3,981 245,329 Nov-13 167,088 $15,267,662 $13,613,337 $12,471,363 $19,703,250 $248,015 $9,964,660 3,648 12,248 65,813 155,506 3,563 225,016 Dec-13 167,095 $15,442,506 $17,258,294 $12,277,623 $21,341,333 $220,424 $10,948,437 2,526 12,562 67,104 151,438 3,219 246,092


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 3 - HISTORICAL TREND (36 MONTH CONTINUOUS MEMBERSHIP FOR ALL GHC GROUP AND INDIVIDUAL PLANS)

Incurred Allowed Amount Incurred Utilization Counts

IncurredJan-11Feb-11Mar-11Apr-11

May-11Jun-11Jul-11

Aug-11Sep-11Oct-11Nov-11Dec-11Jan-12Feb-12Mar-12Apr-12

May-12Jun-12Jul-12


May-13Jun-13Jul-13

Aug-13Sep-13Oct-13Nov-13Dec-13

1/1/2015

Inpatient Days

Outpatient Visits

Professional Visits

Other Services

Capitation Services Rx Scripts Inpatient Outpatient Professional Other Capitation Rx Total

$3,433 $845 $158 $122 $89 $40$3,508 $887 $157 $122 $80 $40$3,689 $864 $159 $121 $79 $40$3,799 $857 $161 $123 $74 $40$4,058 $896 $162 $127 $74 $40$3,157 $959 $161 $128 $72 $42$3,757 $986 $164 $125 $75 $41$3,546 $921 $164 $126 $75 $42$3,145 $950 $163 $118 $71 $42$3,220 $965 $163 $115 $69 $40$3,885 $988 $163 $122 $68 $39$3,635 $962 $165 $131 $67 $39$3,288 $1,073 $166 $128 $79 $39$3,249 $986 $171 $129 $74 $40$3,819 $1,025 $171 $129 $65 $41$3,672 $973 $173 $130 $65 $40$3,899 $1,022 $174 $128 $69 $40$3,666 $1,011 $178 $129 $72 $40$3,750 $1,059 $178 $131 $68 $39$4,074 $982 $179 $133 $68 $41$3,957 $991 $180 $123 $73 $40$3,339 $993 $175 $118 $65 $40$4,423 $1,006 $176 $129 $71 $41$4,130 $1,077 $180 $134 $68 $40 10.7% 14.1% 9.2% 9.2% -12.9% 2.6% 9.3%$3,383 $1,075 $174 $126 $71 $40 13.1% 13.0% 10.9% 10.1% -6.9% 3.4% 10.3%$3,327 $1,087 $179 $134 $75 $40 9.0% 10.9% 9.3% 8.6% -6.6% 3.0% 8.4%$4,212 $1,026 $189 $132 $75 $41 9.0% 8.2% 9.7% 8.1% -10.2% 3.1% 7.8%$4,149 $1,085 $182 $135 $75 $41 14.9% 7.3% 9.7% 7.9% -8.3% 3.4% 8.7%$3,817 $1,070 $186 $136 $73 $43 20.6% 5.4% 9.4% 7.2% -6.3% 3.8% 9.2%$3,673 $1,056 $190 $136 $76 $43 20.6% 5.0% 9.4% 6.9% -5.8% 5.1% 9.3%$3,664 $1,108 $183 $136 $74 $43 22.6% 4.5% 8.8% 6.4% -3.2% 6.2% 9.4%$3,656 $1,038 $186 $134 $78 $44 20.5% 4.6% 8.1% 5.8% -2.5% 7.3% 8.9%$3,655 $1,082 $188 $125 $53 $44 17.9% 5.8% 8.5% 6.8% -2.9% 9.3% 9.4%$3,341 $1,073 $187 $121 $86 $45 19.4% 6.3% 8.1% 6.9% -1.5% 9.9% 9.8%$4,185 $1,111 $189 $127 $70 $44 19.0% 7.3% 8.0% 6.5% -2.1% 9.7% 9.8%$6,113 $1,374 $183 $141 $68 $44 15.8% 9.6% 8.2% 8.1% -1.1% 11.2% 10.3%


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 3 - HISTORICAL TREND (36 MONTH CONTINUOUS MEMBERSHIP FOR ALL GHC GROUP AND INDIVIDUAL PLANS)

Cost per Service Claims 12-Month Rolling Trend

IncurredJan-11Feb-11Mar-11Apr-11

May-11Jun-11Jul-11


May-12Jun-12Jul-12


May-13Jun-13Jul-13

Aug-13Sep-13Oct-13Nov-13Dec-13

1/1/2015

Inpatient Days

Outpatient Visits

Professional Visits

Other Services

Capitation Services Rx Scripts Total

Inpatient Days

Outpatient Visits

Professional Visits

Other Services

Capitation Services Rx Scripts Total

4.8% 3.7% 0.8% 5.0% -6.7% 3.5% 3.5% 5.6% 10.0% 8.3% 4.1% -6.7% -0.8% 5.7%6.7% 4.7% 2.5% 6.4% -1.0% 4.0% 4.5% 6.1% 8.0% 8.2% 3.5% -5.9% -0.5% 5.6%1.5% 2.8% 1.3% 5.1% -1.4% 3.4% 3.5% 7.5% 7.9% 7.9% 3.4% -5.2% -0.3% 4.7%0.9% 1.8% 1.4% 4.9% -8.3% 3.6% 3.5% 8.1% 6.3% 8.2% 3.1% -2.0% -0.4% 4.2%4.8% 1.0% 1.7% 4.9% -8.2% 3.8% 3.6% 9.7% 6.3% 8.0% 3.0% 0.0% -0.3% 5.0%9.8% -0.1% 1.3% 3.7% -7.2% 3.8% 3.2% 10.0% 5.6% 8.1% 3.4% 1.1% 0.1% 5.9%

11.1% -0.4% 1.7% 3.0% -7.0% 4.1% 3.2% 8.7% 5.5% 7.8% 3.9% 1.5% 1.1% 6.0%13.2% -0.7% 1.5% 2.6% -5.9% 4.0% 3.0% 8.5% 5.3% 7.3% 3.8% 3.0% 2.2% 6.3%13.7% -0.5% 1.3% 2.5% -7.0% 3.8% 2.9% 6.1% 5.3% 6.9% 3.4% 5.1% 3.5% 6.0%14.1% 0.3% 2.1% 3.7% -5.4% 4.5% 3.8% 3.5% 5.7% 6.4% 3.1% 2.9% 4.7% 5.5%16.1% 0.3% 1.7% 3.8% -7.2% 4.0% 3.5% 3.0% 6.2% 6.4% 3.2% 6.3% 5.8% 6.2%17.3% 0.6% 1.7% 4.1% -7.2% 3.6% 3.4% 1.6% 6.9% 6.4% 2.5% 5.7% 6.1% 6.3%12.8% 1.3% 2.4% 5.3% -6.2% 4.2% 4.2% 2.9% 8.4% 5.8% 2.9% 5.7% 6.9% 6.1%

3.67% 3.67% 3.67% 3.67% 0.00% 4.53% 3.93% 3.93% 3.93% 3.93% 0.00% 7.70%1/1/2015 Individual Filing Group Health Cooperative

EXHIBIT 3 - HISTORICAL TREND (36 MONTH CONTINUOUS MEMBERSHIP FOR ALL GHC GROUP AND INDIVIDUAL PLANS)GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILING

Cost per Service 12-Month Rolling Trend

Trend Used in Pricing (See Exhibit 4) Trend Used in Pricing (See Exhibit 4)

Utilization 12-Month Rolling Trend

Derivation of Final Total Pricing TrendStep Description

a12/2013 Rolling 12 Months Total Trend 10.3%

b

Average Over Previous 12 Months of 12-Month Rolling Trends 9.3%

cHepatitis C New Treatment Impact 1.1%

dEstimated Impact of Members Aging One Year -2.5%

e 2014 Projected Trend 7.9%

fOffice of the Actuary Anticipated change in trend 1.0%

g 2015 Projected Trend 8.9%h Overall Target 8.4%

Trend Component Buildup

Total TrendObserved 12 Month Rolling Trend as of 12/2013 Final Pricing Trend

Weights (Based on 2013 Historical Trend Incurred Claims)

Inpatient 15.8% 7.7% 20.6%Outpatient 9.6% 7.7% 19.3%Professional 8.2% 7.7% 18.0%Other 8.1% 7.7% 27.7%Capitation -1.1% 0.0% 0.4%Rx 11.2% 12.6% 14.0%Target Total 10.3% 8.4% 100.0%

Cost Per ServiceObserved 12 Month Rolling Trend as of 12/2013 Final Pricing Trend

Weights (Based on 2013 Historical Trend Incurred Claims)

Inpatient 2.9% 3.9% 20.6%Outpatient 8.4% 3.9% 19.3%Professional 5.8% 3.9% 18.0%Other 2.9% 3.9% 27.7%Capitation 5.7% 0.0% 0.4%Rx 6.9% 7.7% 14.0%Target Total 6.1% 4.4% 100.0%

Utilization (includes r Observed 12 Month Rolling Trend as of 12/2013 Final Pricing Trend

Inpatient 12.8% 3.7%Outpatient 1.3% 3.7%Professional 2.4% 3.7%Other 5.3% 3.7%Capitation -6.2% 0.0%Rx 4.2% 4.5%Target Total 4.2% 3.8%


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 4 - FINAL PRICING TREND

12 Month Standard FinalExposure Claims Rolling Claims Deviation Risk and

(From Trend (From Trend Per Member Standard (Percent of ContingencyDate Exhibit) Exhibit) Per Month Deviation PMPM Claims) Factor

Jan-11 167,504 $57,439,190Feb-11 167,498 $52,012,951Mar-11 167,486 $60,987,973Apr-11 167,492 $57,049,487May-11 167,479 $61,340,807Jun-11 167,492 $59,427,906Jul-11 167,515 $57,597,105 $346.16Aug-11 167,514 $62,776,919 $349.73Sep-11 167,532 $58,521,690 $349.68Oct-11 167,479 $59,679,098 $350.35Nov-11 167,473 $61,245,854 $351.75Dec-11 167,504 $63,073,968 $353.81Jan-12 167,465 $58,647,927 $354.42Feb-12 167,445 $63,218,336 $360.01Mar-12 167,449 $67,545,871 $363.28Apr-12 167,456 $61,357,559 $365.43May-12 167,450 $66,613,880 $368.05Jun-12 167,439 $62,847,207 $369.77Jul-12 167,443 $63,951,971 $372.94 $8.53 2.29%Aug-12 167,454 $69,796,672 $376.45 $9.31 2.47%Sep-12 167,444 $62,141,277 $378.26 $9.71 2.57%Oct-12 167,421 $66,877,323 $381.86 $10.03 2.63%Nov-12 167,421 $66,126,338 $384.29 $10.12 2.63%Dec-12 167,432 $67,956,695 $386.74 $10.08 2.61%Jan-13 167,169 $66,744,279 $390.83 $9.85 2.52%Feb-13 167,138 $61,581,018 $390.07 $9.56 2.45%Mar-13 167,117 $70,148,494 $391.43 $9.25 2.36%Apr-13 167,108 $72,932,655 $397.26 $9.35 2.35%May-13 167,119 $75,716,494 $401.86 $9.75 2.43%Jun-13 167,138 $66,996,643 $403.99 $9.84 2.44%Jul-13 167,092 $71,995,088 $408.07 $10.18 2.49%Aug-13 167,105 $73,733,206 $410.10 $10.46 2.55%Sep-13 167,111 $69,099,068 $413.64 $10.68 2.58%Oct-13 167,089 $77,765,714 $419.13 $11.38 2.71%Nov-13 167,088 $71,268,286 $421.77 $11.87 2.81%Dec-13 167,095 $77,488,616 $426.59 $12.50 2.93% 1.00%

Note: Uses claims and membership from Exhibit 3.


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 5 - RISK AND CONTINGENCY CHARGE

Item Description Amounta Estimated 2013 National Premium Base (With Percentage Adjustments) * $557,178,314,000b ACA Total Amount Payable in 2015 $11,300,000,000c Base Premium Fee Percent (b / a) 2.0%d Premium Fee After 50% Reduction For Tax Exempt Organizations Per ACA 1.0%e 2013 GHC Total Statutory Premium (Total Revenues Line of 2013 Statement) $2,253,668,190f 2013 GHC Total Statutory Premium Adjusted for $25 Million and $50 Million Ranges * $2,216,168,190g Estimated Premium Fee Percent of GHC Adjusted Premium Gross 1.0%h Premium Fee Increase Incorporated Into Monthly Rating Formula Trend 1.0%

ACA Percent of Net Premiums* Covered entity’s net premiums written during the calendar year: Taken Into AccountNot more than $25,000,000 0 percentMore than $25,000,000 but not more than $50,000,000 50 percentMore than $50,000,000 100 percent

Notes: From Section 9010 of the Affordable Care Act.Estimated national premium base is from AHIP Estimate of Insurer Fees with Q3 2013 Data prepared by Oliver Wyman.


EXHIBIT 6 - AFFORDABLE CARE ACT (ACA) PREMIUM FEE CALCULATION GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILING

I. Add Pediatric Optical Hardware to All Plansa Pediatric Optical Hardware 2013 Allowed Claims (Plans that cover) $31,673b Pediatric Optical Hardware 2013 Member Months (Plans that cover) 28,750 c Pediatric Optical Hardware 2013 Allowed Claims pmpm (Plans that cover) $1.10d Pediatric 2013 Member Months (Plans that don't cover) 15,640 e Pediatric 2013 Optical Hardware Allowed Claims (Plans that don't cover) $0f Pediatric Optical Hardware 2013 Allowed Claims To Add $17,230g "Other" Allowed 2013 Allowed Claims PMPM (from Rate Template) $86.44h Total 2013 Member Months (from Rate Template) 269,820 i Total "Other" Allowed Allowed Claims from Rate Template $23,322,538j Net Claim Impact Factor for "Other" Category 1.001k Net PMPM Claim Impact $0.06

II. Add Pediatric Vision Exam to All Plansa Pediatric Vision Exam 2013 Allowed Claims (Plans that cover) $99,359b Pediatric Vision Exam 2013 Member Months (Plans that cover) 31,894 c Pediatric Vision Exam 2013 Allowed Claims pmpm (Plans that cover) $3.12d Pediatric 2013 Member Months (Plans that don't cover) 12,496 e Pediatric 2013 Vision Exam Allowed Claims (Plans that don't cover) $4,316f Pediatric Vision Exam 2013 Allowed Claims To Add $34,613g "Professional" Allowed 2013 Allowed Claims PMPM (from Rate Template) $57.68h Total 2013 Member Months (from Rate Template) 269,820 i Total "Professional" Allowed Allowed Claims from Rate Template $15,562,247j Net Claim Impact Factor for "Professional" Category 1.002k Net PMPM Claim Impact $0.13

III. Inpatient Hospital Maternity Adjustment for Catastrophic Plansa Maternity Allowed Claims - Comprehensive plans $1,584,084b Female member months Adult age 19-48 Comprehensive Plans 14,178 c Maternity Allowed Claims pmpm - Comprehensive plans $111.73d Maternity Allowed Claims - Catastrophic plans $183,997e Female member months Adult age 19-48 Catastrophic Plans 40,962 f New Maternity Allowed Claims for Catastrophic Plans $4,392,617g Reduction Factor for Members Needing Maternity Choosing Comp. Plan 0.25h Adjusted New Maternity Allowed Claims for Catastrophic Plans $1,098,154i "Inpatient Hospital" Allowed 2013 Allowed Claims PMPM (from Rate Template) $71.07j Total 2013 Member Months (from Rate Template) 269,820 k Total "Inpatient Hospital" Allowed Allowed Claims from Rate Template $19,174,875l Net Claim Impact Factor for "Inpatient Hospital" Category 1.057

m Net PMPM Claim Impact $4.07

IV. Professional Maternity Adjustment for Catastrophic Plansa Maternity Allowed Claims - Comprehensive plans $872,277b Female member months Adult age 19-48 Comprehensive Plans 14,178 c Maternity Allowed Claims pmpm - Comprehensive plans $61.52d Maternity Allowed Claims - Catastrophic plans $140,255e Female member months Adult age 19-48 Catastrophic Plans 40,962 f New Maternity Allowed Claims for Catastrophic Plans $2,379,862g Reduction Factor for Members Needing Maternity Choosing Comp Plan 0.25h Adjusted New Maternity Allowed Claims for Catastrophic Plans $594,965i "Professional" Allowed 2013 Allowed Claims PMPM (from Rate Template) $57.68j Total 2013 Member Months (from Rate Template) 269,820 k Total "Professional" Allowed Allowed Claims from Rate Template $15,562,247l Net Claim Impact Factor for "Professional" Category 1.038

m Net PMPM Claim Impact $2.21

V. Drug Adjustment for Catastrophic Plansa Drug Allowed Claims for Comprehensive plans $7,660,492b Comprehensive member months 62,636 c Drug Allowed Claims pmpm - Comprehensive plans $122.30d Comprehensive ACA age factor 1.633e Drug Allowed Claims - Catastrophic plans $1,467,120f Cat member months 207,184 g Drug Allowed Claims pmpm - Catastrophic plans $7.08h Catastrophic ACA age factor 1.590i Total Drug Allowed Claims $9,127,612j Reduction Factor for Members Needing Drugs Choosing Comp. Plan 0.36k New Drug Allowed Claims Adjusted for ACA Age Factor $7,415,361l "Drug" Allowed 2013 Allowed Claims PMPM (from Rate Template) $33.83

m Total 2013 Member Months (from Rate Template) 269,820 n Total "Drug" Allowed Allowed Claims from Rate Template $9,127,612o Adjusted Net Claim Impact Factor for "Drug" Category 1.812p Net PMPM Claim Impact $27.48q Estimated Catastrophic Drug Claims $8,882,481r Estimated Catastrophic Drug Claims PMPM $42.87s Estimated Total Drug Claims PMPM $61.31

EXHIBIT 7 - BENEFIT ADJUSTMENTSGROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILING

t Overall ACA Age Factor 1.600

VI. Add Pediatric Dental To All Plansa Total Weighted Contracted Pediatric Dental Paid Rate PMPM $39.07b Pediatric Dental Actuarial Value 0.681c Total Pediatric Dental Allowed PMPM $57.37d Pediatric Member Months 44,390 e Total Pediatric Dental Allowed $2,546,721f "Other" Allowed 2013 Claims PMPM (from Rate Template) $86.44g Total 2013 Member Months (from Rate Template) 269,820 h Total "Other" Allowed Claims from Rate Template $23,322,538i Net Claim Impact Factor for "Other" Category 1.109j Net PMPM Claim Impact $9.44

VII. Remove Adult Vision Exam * / Add To All Plans - Additional Claimsa Adult Vision Exam 2013 Allowed Claims (Plans that cover) $899,169b Adult Vision Exam 2013 Member Months (Plans that cover) 161,886 c Adult Vision Exam 2013 Allowed Claims pmpm (Plans that cover) $5.55d Adult 2013 Member Months (Plans that don't cover) 63,544 e Adult 2013 Vision Exam Allowed Claims (Plans that don't cover) $78,395f Adult Vision Exam 2013 Allowed Claims To Remove $977,563g "Professional" Allowed 2013 Allowed Allowed Claims PMPM (from Rate Template) $57.68h Total 2013 Member Months (from Rate Template) 269,820 i Total "Professional" Allowed Allowed Allowed Claims from Rate Template $15,562,247j Net Claim Impact Factor for "Professional" Category to Remove Adult Vision Exam 0.937k Net PMPM Claim Impact to Remove Adult Vision Exam -$3.62l Additional Adult Vision Exam Allowed Claims $274,549.72

m Net Claim Impact Factor for "Professional" Category to Add Adult Vision Exam 1.018n Net PMPM Claim Impact to Add Adult Vision Exam $1.02

VIII. Remove Adult Optical Hardware from All Plansa Adult Optical Hardware 2013 Allowed Claims (All Plans) $349,767b Total 2013 Member Months (from Rate Template) 269,820 c Total "Other" Allowed Allowed Claims from Rate Template $23,322,538d Net Claim Impact Factor for "Other" Category 0.985e Net PMPM Claim Impact -$1.30

IX. Maternity Summarya Total Adjusted Maternity Claims (Inpatient and Professional) $4,473,733.07b Female age 19-48 Member Months 55,140 c Adjusted Total Maternity PMPM Just For Female age 19-48 Population $81.13d Adjusted Total Maternity PMPM Over Whole Population $16.58

X. Benefit Category Other Adjustmenta Inpatient Hospital = III.(l) 1.057b Outpatient Hospital (No adjustments) 1.000c Professional =1+(IV.(l)-1)+(II.(j)-1)+(VII.(m)-1) 1.058d Other Medical =1+(VI.(i)-1)+(I.(j)-1)+(VIII.(d)-1) 1.095e Capitation (No adjustments) 1.000f Prescription Drug = V.(o) 1.812

X. Benefit Category

Demographic Change Factor 2013 to March

2014

URRT Factor (Other Adj. times Demo. Change)

a Inpatient Hospital 1.068 1.129b Outpatient Hospital 1.068 1.068c Professional 1.068 1.130d Other Medical 1.068 1.169e Capitation 1.068 1.068f Prescription Drug 1.068 1.936

* Removed For Index Rate and Added For Final Rates Through Pricing AVs.


Item1 2013 Administrative Cost For GHC Individual Not Including Group Conversion $11,301,3852 2013 Administrative Cost For GHO Individual Not Including Group Conversion $16,844,0533 Total Adminstrative Cost $28,145,4384 GHC and GHO Individual Member Months Not Including Group Conversion 689,301 5 2013 Total Administrative Cost pmpm $40.836 Fixed (pmpm) Administrative Cost as a % of Total Adminstrative Cost 73.2%7 Variable (Claims Related) Administrative Cost as a % of Total Administrative Cost * 26.8%8 Fixed (pmpm) Administrative Cost $29.899 Fixed Administrative Trend to 2015 3%

10 Fixed 2015 Administrative Cost $31.7111 2013 GHC Individual Premium Not Including Group Conversion $69,744,636

12 Total GHC Individual 2013 Member Months Not Including Group Conversion 269,82013 Variable (Claims Related) Administrative Cost as a % of Premium 4.23%14 2015 Average Premium PMPM $394.9915 2015 Total Administrative Cost PMPM $48.42

* Estimate is derived using 2013 GHO and GHC combined Annual Statement Underwriting and InvestmentExhibit Part 3 Analysis of Expenses. Cost Containment plus Other Claims Adjustment Expenses = Variable Claims Expense.


EXHIBIT 8 - ADMINISTRATION COST CALCULATIONGROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILING

Percent of Premium Commission Percent of Premium Commission Percent of Premium Commission7/1/2012 to 12/31/2013 1/1/2014 to 12/31/2014 1/1/2015 to 12/31/20156.75% 6.50% 6.00%

Item Description Amount1 1/1/2013 to 12/31/2013 Commission Payout Including Group Conversion $1,312,0842 1/1/2013 to 12/31/2013 Commission Payout Adjusted for 1/1/2015 Level $1,166,2973 1/1/2013 to 12/31/2013 Earned Premium Including Group Conversion $69,566,8164 Commission as a Percent of Premium Used in Pricing = 2. / 3. 1.68%


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 9 - COMMISSION PERCENTAGE CALCULATION





Plan ID: 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001Exchange Plan?: Yes Yes Yes Yes Yes No No No No

Plan Adjusted Index Rate From Unified Rating Template: $515.53 $422.80 $346.04 $332.37 $289.62 $522.73 $428.69 $350.85 $333.21Composite Factor For Age,Area: 1.727 1.727 1.727 1.727 1.727 1.727 1.727 1.727 1.727Calibrated Plan Adjusted Index Rate (Used to Build Final Rates): $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.91

AGEBANDTotal 3-2014 Members * Age Factor

0-20 4,855 0.63521 395 1.00022 377 1.00023 377 1.00024 327 1.00025 383 1.00426 628 1.02427 598 1.04828 531 1.08729 571 1.11930 545 1.13531 482 1.15932 499 1.18333 504 1.19834 523 1.21435 504 1.22236 452 1.23037 467 1.23838 450 1.24639 514 1.26240 499 1.27841 517 1.30242 543 1.32543 585 1.35744 618 1.39745 599 1.44446 582 1.50047 584 1.56348 628 1.63549 685 1.70650 708 1.78651 799 1.86552 763 1.95253 846 2.04054 841 2.13555 887 2.23056 939 2.33357 961 2.43758 1,020 2.54859 1,041 2.60360 1,181 2.71461 1,272 2.81062 1,371 2.87363 1,385 2.952

64+ 1,342 3.000Grand Total 35,178Total Age 21+ 30,323Total Age 0-20 4,855* 0-20 Age band doesn't include 4 or more children in a family.

Non-Tobacco User Tobacco User TotalAge 21+ Member Months: 28,914 1,409 30,323 Rating Factor 1.0 1.221+ Member Months Percent of Total 95.4% 4.6% 100.0%Tobacco Use Load Factor - 0.200

Age Factor: 1.7083 Average Age Associated with Age Factor: 49

1.7233

Rate Area 1 2 4 5 CompositeArea Factor 1.000 1.037 0.956 1.004Member Months 13,414 14,738 3,769 3,405 35,326Percent Members In Area 38.0% 41.7% 10.7% 9.6% 100.0%Area Load 0.000 0.037 -0.044 0.004 1.011


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 10 - RATE ADJUSTMENTS

Total Composite Age-Tobacco Use Factor (Used to Calculate Plan Adjusted Index Rate):


Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $189.52 $155.43 $127.21 $122.19 $106.47 $192.17 $157.60 $128.98 $122.5021 $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.9122 $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.9123 $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.9124 $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.9125 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6826 $305.63 $250.65 $205.15 $197.04 $171.70 $309.90 $254.15 $208.00 $197.5427 $312.79 $256.53 $209.95 $201.66 $175.72 $317.16 $260.10 $212.87 $202.1728 $324.43 $266.07 $217.77 $209.16 $182.26 $328.96 $269.78 $220.80 $209.6929 $333.98 $273.91 $224.18 $215.32 $187.63 $338.65 $277.72 $227.30 $215.8730 $338.76 $277.82 $227.38 $218.40 $190.31 $343.49 $281.70 $230.55 $218.9531 $345.92 $283.70 $232.19 $223.02 $194.34 $350.75 $287.65 $235.42 $223.5832 $353.08 $289.57 $237.00 $227.63 $198.36 $358.01 $293.61 $240.30 $228.2133 $357.56 $293.24 $240.00 $230.52 $200.88 $362.55 $297.33 $243.34 $231.1134 $362.33 $297.16 $243.21 $233.60 $203.56 $367.40 $301.30 $246.59 $234.1935 $364.72 $299.12 $244.81 $235.14 $204.90 $369.82 $303.29 $248.22 $235.7436 $367.11 $301.08 $246.41 $236.68 $206.24 $372.24 $305.27 $249.84 $237.2837 $369.50 $303.03 $248.02 $238.22 $207.58 $374.66 $307.26 $251.47 $238.8238 $371.88 $304.99 $249.62 $239.76 $208.92 $377.08 $309.24 $253.09 $240.3739 $376.66 $308.91 $252.83 $242.84 $211.61 $381.92 $313.22 $256.34 $243.4540 $381.44 $312.83 $256.03 $245.91 $214.29 $386.76 $317.19 $259.59 $246.5441 $388.60 $318.70 $260.84 $250.53 $218.31 $394.03 $323.14 $264.47 $251.1742 $395.46 $324.33 $265.45 $254.96 $222.17 $400.99 $328.85 $269.14 $255.6143 $405.01 $332.16 $271.86 $261.12 $227.54 $410.67 $336.79 $275.64 $261.7844 $416.95 $341.95 $279.87 $268.81 $234.24 $422.78 $346.72 $283.76 $269.4945 $430.98 $353.46 $289.29 $277.86 $242.12 $437.00 $358.39 $293.31 $278.5646 $447.69 $367.17 $300.51 $288.63 $251.51 $453.95 $372.29 $304.69 $289.3647 $466.50 $382.59 $313.13 $300.76 $262.08 $473.01 $387.92 $317.48 $301.5248 $487.99 $400.21 $327.55 $314.61 $274.15 $494.80 $405.79 $332.11 $315.4149 $509.18 $417.59 $341.78 $328.27 $286.05 $516.29 $423.41 $346.53 $329.1050 $533.05 $437.17 $357.80 $343.67 $299.47 $540.50 $443.27 $362.78 $344.5451 $556.63 $456.51 $373.63 $358.87 $312.71 $564.41 $462.87 $378.83 $359.7852 $582.60 $477.81 $391.06 $375.61 $327.30 $590.74 $484.47 $396.50 $376.5653 $608.86 $499.35 $408.69 $392.54 $342.06 $617.37 $506.31 $414.37 $393.5454 $637.22 $522.60 $427.72 $410.82 $357.99 $646.12 $529.89 $433.67 $411.8655 $665.57 $545.85 $446.75 $429.10 $373.92 $674.87 $553.46 $452.97 $430.1956 $696.31 $571.07 $467.39 $448.92 $391.19 $706.04 $579.03 $473.89 $450.0657 $727.35 $596.52 $488.22 $468.93 $408.62 $737.51 $604.84 $495.01 $470.1258 $760.48 $623.69 $510.46 $490.29 $427.24 $771.11 $632.39 $517.56 $491.5359 $776.90 $637.16 $521.48 $500.87 $436.46 $787.75 $646.04 $528.73 $502.1460 $810.03 $664.33 $543.72 $522.23 $455.07 $821.34 $673.59 $551.28 $523.5661 $838.68 $687.82 $562.95 $540.70 $471.17 $850.40 $697.41 $570.78 $542.0862 $857.48 $703.25 $575.57 $552.83 $481.73 $869.46 $713.05 $583.58 $554.2363 $881.06 $722.58 $591.40 $568.03 $494.98 $893.37 $732.66 $599.62 $569.4764 $895.38 $734.33 $601.01 $577.26 $503.03 $907.89 $744.57 $609.37 $578.73

65+ $895.38 $734.33 $601.01 $577.26 $503.03 $907.89 $744.57 $609.37 $578.73






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $196.54 $161.18 $131.92 $126.71 $110.41 $199.28 $163.43 $133.76 $127.0321 $309.51 $253.83 $207.75 $199.54 $173.88 $313.83 $257.37 $210.64 $200.0522 $309.51 $253.83 $207.75 $199.54 $173.88 $313.83 $257.37 $210.64 $200.0523 $309.51 $253.83 $207.75 $199.54 $173.88 $313.83 $257.37 $210.64 $200.0524 $309.51 $253.83 $207.75 $199.54 $173.88 $313.83 $257.37 $210.64 $200.0525 $310.74 $254.85 $208.58 $200.34 $174.57 $315.08 $258.40 $211.48 $200.8526 $316.93 $259.93 $212.74 $204.33 $178.05 $321.36 $263.55 $215.69 $204.8527 $324.36 $266.02 $217.72 $209.12 $182.23 $328.89 $269.73 $220.75 $209.6528 $336.43 $275.92 $225.82 $216.90 $189.01 $341.13 $279.76 $228.97 $217.4529 $346.34 $284.04 $232.47 $223.29 $194.57 $351.18 $288.00 $235.71 $223.8530 $351.29 $288.10 $235.80 $226.48 $197.35 $356.20 $292.12 $239.08 $227.0531 $358.72 $294.19 $240.78 $231.27 $201.53 $363.73 $298.30 $244.13 $231.8532 $366.15 $300.29 $245.77 $236.06 $205.70 $371.26 $304.47 $249.19 $236.6633 $370.79 $304.09 $248.88 $239.05 $208.31 $375.97 $308.33 $252.35 $239.6634 $375.74 $308.15 $252.21 $242.24 $211.09 $380.99 $312.45 $255.72 $242.8635 $378.22 $310.19 $253.87 $243.84 $212.48 $383.50 $314.51 $257.40 $244.4636 $380.69 $312.22 $255.53 $245.44 $213.87 $386.01 $316.57 $259.09 $246.0637 $383.17 $314.25 $257.19 $247.03 $215.26 $388.52 $318.63 $260.77 $247.6638 $385.64 $316.28 $258.86 $248.63 $216.65 $391.03 $320.69 $262.46 $249.2639 $390.60 $320.34 $262.18 $251.82 $219.44 $396.05 $324.80 $265.83 $252.4640 $395.55 $324.40 $265.50 $255.01 $222.22 $401.07 $328.92 $269.20 $255.6641 $402.98 $330.49 $270.49 $259.80 $226.39 $408.61 $335.10 $274.25 $260.4642 $410.10 $336.33 $275.27 $264.39 $230.39 $415.82 $341.02 $279.10 $265.0643 $420.00 $344.45 $281.92 $270.78 $235.95 $425.87 $349.26 $285.84 $271.4644 $432.38 $354.61 $290.23 $278.76 $242.91 $438.42 $359.55 $294.26 $279.4745 $446.93 $366.54 $299.99 $288.14 $251.08 $453.17 $371.65 $304.16 $288.8746 $464.26 $380.75 $311.62 $299.31 $260.82 $470.74 $386.06 $315.96 $300.0747 $483.76 $396.74 $324.71 $311.88 $271.77 $490.52 $402.27 $329.23 $312.6748 $506.04 $415.02 $339.67 $326.25 $284.29 $513.11 $420.81 $344.40 $327.0849 $528.02 $433.04 $354.42 $340.42 $296.64 $535.39 $439.08 $359.35 $341.2850 $552.78 $453.35 $371.04 $356.38 $310.55 $560.50 $459.67 $376.20 $357.2851 $577.23 $473.40 $387.45 $372.14 $324.28 $585.29 $480.00 $392.84 $373.0952 $604.16 $495.48 $405.53 $389.50 $339.41 $612.59 $502.39 $411.17 $390.4953 $631.39 $517.82 $423.81 $407.06 $354.71 $640.21 $525.04 $429.70 $408.1054 $660.80 $541.94 $443.55 $426.02 $371.23 $670.03 $549.49 $449.72 $427.1055 $690.20 $566.05 $463.28 $444.98 $387.75 $699.84 $573.94 $469.73 $446.1156 $722.08 $592.20 $484.68 $465.53 $405.66 $732.16 $600.45 $491.42 $466.7157 $754.27 $618.59 $506.29 $486.28 $423.74 $764.80 $627.22 $513.33 $487.5158 $788.62 $646.77 $529.35 $508.43 $443.04 $799.64 $655.79 $536.71 $509.7259 $805.64 $660.73 $540.77 $519.41 $452.61 $816.90 $669.94 $548.29 $520.7260 $840.00 $688.91 $563.83 $541.56 $471.91 $851.73 $698.51 $571.68 $542.9361 $869.71 $713.27 $583.78 $560.71 $488.60 $881.86 $723.22 $591.90 $562.1362 $889.21 $729.27 $596.87 $573.28 $499.56 $901.63 $739.43 $605.17 $574.7463 $913.66 $749.32 $613.28 $589.05 $513.29 $926.42 $759.77 $621.81 $590.5464 $928.52 $761.49 $623.25 $598.62 $521.64 $941.49 $772.12 $631.92 $600.14

65+ $928.52 $761.49 $623.25 $598.62 $521.64 $941.49 $772.12 $631.92 $600.14






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315



0-20* $181.18 $148.59 $121.62 $116.81 $101.79 $183.72 $150.67 $123.31 $117.1121 $285.33 $234.01 $191.52 $183.96 $160.30 $289.32 $237.27 $194.19 $184.4222 $285.33 $234.01 $191.52 $183.96 $160.30 $289.32 $237.27 $194.19 $184.4223 $285.33 $234.01 $191.52 $183.96 $160.30 $289.32 $237.27 $194.19 $184.4224 $285.33 $234.01 $191.52 $183.96 $160.30 $289.32 $237.27 $194.19 $184.4225 $286.47 $234.94 $192.29 $184.69 $160.94 $290.47 $238.22 $194.96 $185.1626 $292.18 $239.62 $196.12 $188.37 $164.14 $296.26 $242.96 $198.85 $188.8527 $299.03 $245.24 $200.72 $192.78 $167.99 $303.20 $248.66 $203.51 $193.2728 $310.15 $254.37 $208.18 $199.96 $174.24 $314.49 $257.91 $211.08 $200.4729 $319.28 $261.85 $214.31 $205.85 $179.37 $323.74 $265.50 $217.29 $206.3730 $323.85 $265.60 $217.38 $208.79 $181.94 $328.37 $269.30 $220.40 $209.3231 $330.70 $271.21 $221.97 $213.20 $185.78 $335.32 $275.00 $225.06 $213.7432 $337.55 $276.83 $226.57 $217.62 $189.63 $342.26 $280.69 $229.72 $218.1733 $341.83 $280.34 $229.44 $220.38 $192.04 $346.60 $284.25 $232.64 $220.9434 $346.39 $284.08 $232.51 $223.32 $194.60 $351.23 $288.05 $235.74 $223.8935 $348.67 $285.96 $234.04 $224.79 $195.88 $353.54 $289.94 $237.30 $225.3636 $350.96 $287.83 $235.57 $226.26 $197.17 $355.86 $291.84 $238.85 $226.8437 $353.24 $289.70 $237.10 $227.74 $198.45 $358.17 $293.74 $240.40 $228.3138 $355.52 $291.57 $238.64 $229.21 $199.73 $360.49 $295.64 $241.96 $229.7939 $360.09 $295.32 $241.70 $232.15 $202.30 $365.12 $299.43 $245.06 $232.7440 $364.65 $299.06 $244.77 $235.09 $204.86 $369.75 $303.23 $248.17 $235.6941 $371.50 $304.68 $249.36 $239.51 $208.71 $376.69 $308.93 $252.83 $240.1242 $378.06 $310.06 $253.77 $243.74 $212.39 $383.34 $314.38 $257.30 $244.3643 $387.19 $317.55 $259.90 $249.63 $217.52 $392.60 $321.98 $263.51 $250.2644 $398.61 $326.91 $267.56 $256.99 $223.94 $404.17 $331.47 $271.28 $257.6445 $412.02 $337.91 $276.56 $265.63 $231.47 $417.77 $342.62 $280.41 $266.3046 $428.00 $351.01 $287.28 $275.93 $240.45 $433.97 $355.90 $291.28 $276.6347 $445.97 $365.75 $299.35 $287.52 $250.55 $452.20 $370.85 $303.51 $288.2548 $466.52 $382.60 $313.14 $300.77 $262.09 $473.03 $387.94 $317.49 $301.5349 $486.77 $399.22 $326.74 $313.83 $273.47 $493.57 $404.78 $331.28 $314.6250 $509.60 $417.94 $342.06 $328.54 $286.29 $516.72 $423.76 $346.82 $329.3851 $532.14 $436.42 $357.19 $343.08 $298.96 $539.57 $442.51 $362.16 $343.9552 $556.97 $456.78 $373.85 $359.08 $312.90 $564.75 $463.15 $379.05 $359.9953 $582.07 $477.37 $390.71 $375.27 $327.01 $590.21 $484.03 $396.14 $376.2254 $609.18 $499.61 $408.90 $392.74 $342.24 $617.69 $506.57 $414.59 $393.7455 $636.29 $521.84 $427.10 $410.22 $357.46 $645.18 $529.11 $433.04 $411.2656 $665.68 $545.94 $446.82 $429.17 $373.97 $674.97 $553.55 $453.04 $430.2657 $695.35 $570.28 $466.74 $448.30 $390.65 $705.06 $578.23 $473.23 $449.4458 $727.02 $596.25 $488.00 $468.72 $408.44 $737.18 $604.56 $494.79 $469.9159 $742.72 $609.12 $498.53 $478.84 $417.25 $753.09 $617.61 $505.47 $480.0560 $774.39 $635.10 $519.79 $499.25 $435.05 $785.20 $643.95 $527.02 $500.5261 $801.78 $657.56 $538.18 $516.91 $450.44 $812.98 $666.73 $545.66 $518.2262 $819.75 $672.30 $550.24 $528.50 $460.54 $831.21 $681.68 $557.90 $529.8463 $842.30 $690.79 $565.37 $543.04 $473.20 $854.06 $700.42 $573.24 $544.4164 $855.99 $702.02 $574.56 $551.87 $480.89 $867.95 $711.81 $582.56 $553.26

65+ $855.99 $702.02 $574.56 $551.87 $480.89 $867.95 $711.81 $582.56 $553.26






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $190.28 $156.06 $127.72 $122.68 $106.90 $192.94 $158.23 $129.50 $122.9921 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6822 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6823 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6824 $299.66 $245.76 $201.14 $193.19 $168.35 $303.84 $249.18 $203.94 $193.6825 $300.86 $246.74 $201.94 $193.96 $169.02 $305.06 $250.18 $204.75 $194.4626 $306.85 $251.65 $205.97 $197.83 $172.39 $311.13 $255.16 $208.83 $198.3327 $314.04 $257.55 $210.79 $202.46 $176.43 $318.43 $261.14 $213.73 $202.9828 $325.73 $267.14 $218.64 $210.00 $182.99 $330.28 $270.86 $221.68 $210.5329 $335.32 $275.00 $225.07 $216.18 $188.38 $340.00 $278.84 $228.20 $216.7330 $340.11 $278.93 $228.29 $219.27 $191.07 $344.86 $282.82 $231.47 $219.8331 $347.30 $284.83 $233.12 $223.91 $195.11 $352.15 $288.80 $236.36 $224.4832 $354.49 $290.73 $237.95 $228.55 $199.15 $359.45 $294.78 $241.26 $229.1233 $358.99 $294.42 $240.96 $231.44 $201.68 $364.00 $298.52 $244.32 $232.0334 $363.78 $298.35 $244.18 $234.53 $204.37 $368.86 $302.51 $247.58 $235.1335 $366.18 $300.31 $245.79 $236.08 $205.72 $371.30 $304.50 $249.21 $236.6836 $368.58 $302.28 $247.40 $237.63 $207.07 $373.73 $306.49 $250.84 $238.2337 $370.98 $304.25 $249.01 $239.17 $208.41 $376.16 $308.49 $252.47 $239.7838 $373.37 $306.21 $250.62 $240.72 $209.76 $378.59 $310.48 $254.10 $241.3339 $378.17 $310.14 $253.84 $243.81 $212.45 $383.45 $314.47 $257.37 $244.4340 $382.96 $314.08 $257.06 $246.90 $215.15 $388.31 $318.46 $260.63 $247.5241 $390.15 $319.98 $261.88 $251.54 $219.19 $395.60 $324.44 $265.53 $252.1742 $397.05 $325.63 $266.51 $255.98 $223.06 $402.59 $330.17 $270.22 $256.6343 $406.63 $333.49 $272.95 $262.16 $228.45 $412.31 $338.14 $276.74 $262.8344 $418.62 $343.32 $280.99 $269.89 $235.18 $424.47 $348.11 $284.90 $270.5745 $432.70 $354.87 $290.44 $278.97 $243.09 $438.75 $359.82 $294.48 $279.6846 $449.49 $368.63 $301.71 $289.79 $252.52 $455.76 $373.77 $305.90 $290.5247 $468.36 $384.12 $314.38 $301.96 $263.12 $474.91 $389.47 $318.75 $302.7248 $489.94 $401.81 $328.86 $315.87 $275.25 $496.78 $407.41 $333.44 $316.6749 $511.21 $419.26 $343.14 $329.58 $287.20 $518.36 $425.11 $347.92 $330.4250 $535.19 $438.92 $359.23 $345.04 $300.67 $542.66 $445.04 $364.23 $345.9151 $558.86 $458.34 $375.12 $360.30 $313.97 $566.67 $464.73 $380.34 $361.2252 $584.93 $479.72 $392.62 $377.11 $328.61 $593.10 $486.41 $398.08 $378.0753 $611.30 $501.34 $410.32 $394.11 $343.43 $619.84 $508.33 $416.03 $395.1154 $639.77 $524.69 $429.43 $412.46 $359.42 $648.70 $532.01 $435.40 $413.5155 $668.23 $548.04 $448.54 $430.82 $375.41 $677.57 $555.68 $454.78 $431.9156 $699.10 $573.35 $469.26 $450.72 $392.75 $708.86 $581.34 $475.78 $451.8657 $730.26 $598.91 $490.18 $470.81 $410.26 $740.46 $607.26 $496.99 $472.0058 $763.53 $626.19 $512.50 $492.25 $428.95 $774.19 $634.92 $519.63 $493.5059 $780.01 $639.70 $523.56 $502.88 $438.20 $790.90 $648.62 $530.85 $504.1560 $813.27 $666.98 $545.89 $524.32 $456.89 $824.63 $676.28 $553.48 $525.6561 $842.04 $690.58 $565.20 $542.87 $473.05 $853.80 $700.20 $573.06 $544.2462 $860.91 $706.06 $577.87 $555.04 $483.66 $872.94 $715.90 $585.91 $556.4563 $884.59 $725.47 $593.76 $570.30 $496.96 $896.94 $735.59 $602.02 $571.7564 $898.97 $737.27 $603.42 $579.57 $505.04 $911.52 $747.55 $611.81 $581.04

65+ $898.97 $737.27 $603.42 $579.57 $505.04 $911.52 $747.55 $611.81 $581.04






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $189.52 $155.43 $127.21 $122.19 $106.47 $192.17 $157.60 $128.98 $122.5021 $358.16 $293.73 $240.40 $230.91 $201.21 $363.16 $297.83 $243.75 $231.4922 $358.16 $293.73 $240.40 $230.91 $201.21 $363.16 $297.83 $243.75 $231.4923 $358.16 $293.73 $240.40 $230.91 $201.21 $363.16 $297.83 $243.75 $231.4924 $358.16 $293.73 $240.40 $230.91 $201.21 $363.16 $297.83 $243.75 $231.4925 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4226 $366.75 $300.78 $246.17 $236.45 $206.04 $371.87 $304.98 $249.60 $237.0527 $375.35 $307.83 $251.94 $241.99 $210.87 $380.59 $312.12 $255.45 $242.6028 $389.32 $319.29 $261.32 $250.99 $218.72 $394.75 $323.74 $264.95 $251.6329 $400.78 $328.69 $269.01 $258.38 $225.15 $406.37 $333.27 $272.75 $259.0430 $406.51 $333.39 $272.86 $262.08 $228.37 $412.18 $338.03 $276.65 $262.7431 $415.10 $340.44 $278.63 $267.62 $233.20 $420.90 $345.18 $282.50 $268.3032 $423.70 $347.49 $284.40 $273.16 $238.03 $429.62 $352.33 $288.35 $273.8533 $429.07 $351.89 $288.00 $276.63 $241.05 $435.06 $356.80 $292.01 $277.3334 $434.80 $356.59 $291.85 $280.32 $244.27 $440.87 $361.56 $295.91 $281.0335 $437.67 $358.94 $293.77 $282.17 $245.88 $443.78 $363.95 $297.86 $282.8836 $440.53 $361.29 $295.70 $284.01 $247.49 $446.68 $366.33 $299.81 $284.7337 $443.40 $363.64 $297.62 $285.86 $249.10 $449.59 $368.71 $301.76 $286.5938 $446.26 $365.99 $299.54 $287.71 $250.71 $452.50 $371.09 $303.71 $288.4439 $451.99 $370.69 $303.39 $291.40 $253.93 $458.31 $375.86 $307.61 $292.1440 $457.72 $375.39 $307.24 $295.10 $257.15 $464.12 $380.62 $311.51 $295.8541 $466.32 $382.44 $313.01 $300.64 $261.98 $472.83 $387.77 $317.36 $301.4042 $474.56 $389.20 $318.54 $305.95 $266.60 $481.18 $394.62 $322.97 $306.7343 $486.02 $398.60 $326.23 $313.34 $273.04 $492.81 $404.15 $330.77 $314.1344 $500.34 $410.34 $335.85 $322.58 $281.09 $507.33 $416.07 $340.52 $323.3945 $517.18 $424.15 $347.14 $333.43 $290.55 $524.40 $430.06 $351.97 $334.2746 $537.23 $440.60 $360.61 $346.36 $301.82 $544.74 $446.74 $365.62 $347.2447 $559.80 $459.10 $375.75 $360.91 $314.49 $567.62 $465.51 $380.98 $361.8248 $585.58 $480.25 $393.06 $377.53 $328.98 $593.76 $486.95 $398.53 $378.4949 $611.01 $501.11 $410.13 $393.93 $343.26 $619.55 $508.09 $415.84 $394.9250 $639.67 $524.61 $429.36 $412.40 $359.36 $648.60 $531.92 $435.34 $413.4451 $667.96 $547.81 $448.35 $430.64 $375.26 $677.29 $555.45 $454.59 $431.7352 $699.12 $573.37 $469.27 $450.73 $392.76 $708.89 $581.36 $475.80 $451.8753 $730.64 $599.22 $490.43 $471.05 $410.47 $740.84 $607.57 $497.25 $472.2454 $764.66 $627.12 $513.26 $492.98 $429.58 $775.34 $635.86 $520.40 $494.2355 $798.69 $655.02 $536.10 $514.92 $448.70 $809.84 $664.16 $543.56 $516.2356 $835.58 $685.28 $560.86 $538.70 $469.42 $847.25 $694.83 $568.67 $540.0757 $872.82 $715.83 $585.87 $562.72 $490.35 $885.02 $725.81 $594.02 $564.1458 $912.58 $748.43 $612.55 $588.35 $512.68 $925.33 $758.87 $621.07 $589.8459 $932.28 $764.59 $625.77 $601.05 $523.75 $945.30 $775.25 $634.48 $602.5760 $972.03 $797.19 $652.46 $626.68 $546.09 $985.61 $808.31 $661.53 $628.2761 $1,006.42 $825.39 $675.54 $648.85 $565.40 $1,020.48 $836.90 $684.93 $650.4962 $1,028.98 $843.89 $690.68 $663.39 $578.08 $1,043.35 $855.66 $700.29 $665.0763 $1,057.28 $867.10 $709.68 $681.63 $593.97 $1,072.04 $879.19 $719.55 $683.3664 $1,074.47 $881.19 $721.20 $692.72 $603.63 $1,089.48 $893.48 $731.25 $694.47

65+ $1,074.47 $881.19 $721.20 $692.72 $603.63 $1,089.48 $893.48 $731.25 $694.47






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $196.54 $161.18 $131.92 $126.71 $110.41 $199.28 $163.43 $133.76 $127.0321 $371.41 $304.60 $249.30 $239.45 $208.66 $376.60 $308.85 $252.77 $240.0622 $371.41 $304.60 $249.30 $239.45 $208.66 $376.60 $308.85 $252.77 $240.0623 $371.41 $304.60 $249.30 $239.45 $208.66 $376.60 $308.85 $252.77 $240.0624 $371.41 $304.60 $249.30 $239.45 $208.66 $376.60 $308.85 $252.77 $240.0625 $372.89 $305.82 $250.30 $240.41 $209.49 $378.10 $310.08 $253.78 $241.0226 $380.32 $311.91 $255.28 $245.20 $213.66 $385.63 $316.26 $258.83 $245.8227 $389.23 $319.22 $261.27 $250.94 $218.67 $394.67 $323.67 $264.90 $251.5828 $403.72 $331.10 $270.99 $260.28 $226.81 $409.36 $335.72 $274.76 $260.9429 $415.60 $340.85 $278.97 $267.94 $233.49 $421.41 $345.60 $282.85 $268.6230 $421.55 $345.72 $282.96 $271.78 $236.82 $427.44 $350.54 $286.89 $272.4631 $430.46 $353.03 $288.94 $277.52 $241.83 $436.47 $357.95 $292.96 $278.2332 $439.37 $360.34 $294.92 $283.27 $246.84 $445.51 $365.37 $299.02 $283.9933 $444.95 $364.91 $298.66 $286.86 $249.97 $451.16 $370.00 $302.82 $287.5934 $450.89 $369.79 $302.65 $290.69 $253.31 $457.19 $374.94 $306.86 $291.4335 $453.86 $372.22 $304.64 $292.61 $254.98 $460.20 $377.41 $308.88 $293.3536 $456.83 $374.66 $306.64 $294.52 $256.65 $463.21 $379.88 $310.90 $295.2737 $459.80 $377.10 $308.63 $296.44 $258.32 $466.22 $382.35 $312.93 $297.1938 $462.77 $379.53 $310.63 $298.35 $259.98 $469.24 $384.82 $314.95 $299.1139 $468.72 $384.41 $314.62 $302.19 $263.32 $475.26 $389.77 $318.99 $302.9540 $474.66 $389.28 $318.61 $306.02 $266.66 $481.29 $394.71 $323.04 $306.7941 $483.57 $396.59 $324.59 $311.76 $271.67 $490.33 $402.12 $329.10 $312.5542 $492.11 $403.60 $330.32 $317.27 $276.47 $498.99 $409.22 $334.92 $318.0743 $504.00 $413.34 $338.30 $324.93 $283.15 $511.04 $419.11 $343.01 $325.7644 $518.86 $425.53 $348.27 $334.51 $291.49 $526.10 $431.46 $353.12 $335.3645 $536.31 $439.84 $359.99 $345.77 $301.30 $543.80 $445.98 $365.00 $346.6446 $557.11 $456.90 $373.95 $359.17 $312.98 $564.89 $463.27 $379.15 $360.0847 $580.51 $476.09 $389.66 $374.26 $326.13 $588.62 $482.73 $395.08 $375.2148 $607.25 $498.02 $407.61 $391.50 $341.15 $615.73 $504.97 $413.27 $392.4949 $633.62 $519.65 $425.31 $408.50 $355.97 $642.47 $526.89 $431.22 $409.5450 $663.33 $544.02 $445.25 $427.66 $372.66 $672.60 $551.60 $451.44 $428.7451 $692.67 $568.08 $464.94 $446.57 $389.14 $702.35 $576.00 $471.41 $447.7152 $724.99 $594.58 $486.63 $467.41 $407.29 $735.11 $602.87 $493.40 $468.5953 $757.67 $621.39 $508.57 $488.48 $425.66 $768.25 $630.05 $515.65 $489.7254 $792.95 $650.32 $532.26 $511.22 $445.48 $804.03 $659.39 $539.66 $512.5255 $828.24 $679.26 $555.94 $533.97 $465.30 $839.81 $688.73 $563.67 $535.3356 $866.49 $710.63 $581.62 $558.64 $486.79 $878.60 $720.54 $589.71 $560.0557 $905.12 $742.31 $607.54 $583.54 $508.49 $917.76 $752.66 $615.99 $585.0258 $946.35 $776.12 $635.22 $610.12 $531.65 $959.56 $786.94 $644.05 $611.6659 $966.77 $792.88 $648.93 $623.29 $543.13 $980.28 $803.93 $657.95 $624.8760 $1,008.00 $826.69 $676.60 $649.87 $566.29 $1,022.08 $838.21 $686.01 $651.5161 $1,043.65 $855.93 $700.53 $672.85 $586.32 $1,058.23 $867.86 $710.28 $674.5662 $1,067.05 $875.12 $716.24 $687.94 $599.47 $1,081.96 $887.32 $726.20 $689.6863 $1,096.39 $899.18 $735.93 $706.86 $615.95 $1,111.71 $911.72 $746.17 $708.6564 $1,114.22 $913.80 $747.90 $718.35 $625.97 $1,129.79 $926.54 $758.30 $720.17

65+ $1,114.22 $913.80 $747.90 $718.35 $625.97 $1,129.79 $926.54 $758.30 $720.17






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315



0-20* $181.18 $148.59 $121.62 $116.81 $101.79 $183.72 $150.67 $123.31 $117.1121 $342.40 $280.81 $229.83 $220.75 $192.36 $347.18 $284.72 $233.02 $221.3122 $342.40 $280.81 $229.83 $220.75 $192.36 $347.18 $284.72 $233.02 $221.3123 $342.40 $280.81 $229.83 $220.75 $192.36 $347.18 $284.72 $233.02 $221.3124 $342.40 $280.81 $229.83 $220.75 $192.36 $347.18 $284.72 $233.02 $221.3125 $343.77 $281.93 $230.75 $221.63 $193.13 $348.57 $285.86 $233.96 $222.1926 $350.61 $287.55 $235.34 $226.04 $196.97 $355.51 $291.56 $238.62 $226.6227 $358.83 $294.29 $240.86 $231.34 $201.59 $363.84 $298.39 $244.21 $231.9328 $372.19 $305.24 $249.82 $239.95 $209.09 $377.38 $309.49 $253.30 $240.5629 $383.14 $314.22 $257.18 $247.01 $215.25 $388.49 $318.61 $260.75 $247.6430 $388.62 $318.72 $260.85 $250.55 $218.33 $394.05 $323.16 $264.48 $251.1831 $396.84 $325.46 $266.37 $255.84 $222.94 $402.38 $329.99 $270.07 $256.4932 $405.06 $332.20 $271.89 $261.14 $227.56 $410.71 $336.83 $275.67 $261.8033 $410.19 $336.41 $275.33 $264.45 $230.44 $415.92 $341.10 $279.16 $265.1234 $415.67 $340.90 $279.01 $267.99 $233.52 $421.48 $345.65 $282.89 $268.6735 $418.41 $343.15 $280.85 $269.75 $235.06 $424.25 $347.93 $284.76 $270.4436 $421.15 $345.39 $282.69 $271.52 $236.60 $427.03 $350.21 $286.62 $272.2137 $423.89 $347.64 $284.53 $273.28 $238.14 $429.81 $352.49 $288.48 $273.9838 $426.63 $349.89 $286.36 $275.05 $239.68 $432.59 $354.77 $290.35 $275.7539 $432.10 $354.38 $290.04 $278.58 $242.75 $438.14 $359.32 $294.08 $279.2940 $437.58 $358.87 $293.72 $282.11 $245.83 $443.70 $363.88 $297.80 $282.8341 $445.80 $365.61 $299.23 $287.41 $250.45 $452.03 $370.71 $303.40 $288.1442 $453.68 $372.07 $304.52 $292.49 $254.87 $460.01 $377.26 $308.76 $293.2343 $464.63 $381.06 $311.88 $299.55 $261.03 $471.12 $386.37 $316.21 $300.3144 $478.33 $392.29 $321.07 $308.38 $268.72 $485.01 $397.76 $325.53 $309.1645 $494.42 $405.49 $331.87 $318.76 $277.76 $501.33 $411.14 $336.49 $319.5746 $513.59 $421.21 $344.74 $331.12 $288.54 $520.77 $427.09 $349.54 $331.9647 $535.17 $438.90 $359.22 $345.03 $300.65 $542.64 $445.02 $364.22 $345.9048 $559.82 $459.12 $375.77 $360.92 $314.50 $567.64 $465.52 $380.99 $361.8349 $584.13 $479.06 $392.08 $376.59 $328.16 $592.29 $485.74 $397.54 $377.5550 $611.52 $501.52 $410.47 $394.25 $343.55 $620.06 $508.52 $416.18 $395.2551 $638.57 $523.71 $428.63 $411.69 $358.75 $647.49 $531.01 $434.59 $412.7452 $668.36 $548.14 $448.62 $430.90 $375.48 $677.69 $555.78 $454.86 $431.9953 $698.49 $572.85 $468.85 $450.32 $392.41 $708.25 $580.84 $475.37 $451.4654 $731.02 $599.53 $490.68 $471.29 $410.68 $741.23 $607.89 $497.51 $472.4955 $763.54 $626.20 $512.51 $492.26 $428.96 $774.21 $634.93 $519.64 $493.5156 $798.81 $655.13 $536.19 $515.00 $448.77 $809.97 $664.26 $543.64 $516.3157 $834.42 $684.33 $560.09 $537.96 $468.77 $846.08 $693.87 $567.88 $539.3258 $872.43 $715.50 $585.60 $562.46 $490.13 $884.61 $725.48 $593.74 $563.8959 $891.26 $730.94 $598.24 $574.60 $500.71 $903.71 $741.14 $606.56 $576.0660 $929.26 $762.11 $623.75 $599.11 $522.06 $942.24 $772.74 $632.43 $600.6261 $962.13 $789.07 $645.81 $620.30 $540.52 $975.57 $800.07 $654.80 $621.8762 $983.71 $806.76 $660.29 $634.20 $552.64 $997.45 $818.01 $669.48 $635.8163 $1,010.75 $828.95 $678.45 $651.64 $567.84 $1,024.87 $840.50 $687.89 $653.2964 $1,027.19 $842.43 $689.48 $662.24 $577.07 $1,041.54 $854.17 $699.07 $663.92

65+ $1,027.19 $842.43 $689.48 $662.24 $577.07 $1,041.54 $854.17 $699.07 $663.92






Form Number CA-4106, 4108CA-4102, 4103, 4104, 4105, 4110

CA-4096, 4101, 4107 CA-4100, 4109 CA-395715 CA-4113 CA-395915 CA-4095 CA-395315





0-20* $190.28 $156.06 $127.72 $122.68 $106.90 $192.94 $158.23 $129.50 $122.9921 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4222 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4223 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4224 $359.59 $294.91 $241.37 $231.83 $202.02 $364.61 $299.02 $244.72 $232.4225 $361.03 $296.09 $242.33 $232.76 $202.82 $366.07 $300.22 $245.70 $233.3526 $368.22 $301.99 $247.16 $237.39 $206.86 $373.36 $306.20 $250.60 $238.0027 $376.85 $309.06 $252.95 $242.96 $211.71 $382.11 $313.37 $256.47 $243.5728 $390.87 $320.56 $262.37 $252.00 $219.59 $396.33 $325.03 $266.01 $252.6429 $402.38 $330.00 $270.09 $259.42 $226.06 $408.00 $334.60 $273.85 $260.0830 $408.13 $334.72 $273.95 $263.13 $229.29 $413.83 $339.39 $277.76 $263.7931 $416.76 $341.80 $279.74 $268.69 $234.14 $422.58 $346.56 $283.63 $269.3732 $425.39 $348.88 $285.54 $274.25 $238.98 $431.33 $353.74 $289.51 $274.9533 $430.79 $353.30 $289.16 $277.73 $242.01 $436.80 $358.23 $293.18 $278.4434 $436.54 $358.02 $293.02 $281.44 $245.25 $442.64 $363.01 $297.09 $282.1535 $439.42 $360.38 $294.95 $283.30 $246.86 $445.55 $365.40 $299.05 $284.0136 $442.29 $362.74 $296.88 $285.15 $248.48 $448.47 $367.79 $301.01 $285.8737 $445.17 $365.10 $298.81 $287.01 $250.09 $451.39 $370.19 $302.97 $287.7338 $448.05 $367.46 $300.74 $288.86 $251.71 $454.31 $372.58 $304.93 $289.5939 $453.80 $372.17 $304.60 $292.57 $254.94 $460.14 $377.36 $308.84 $293.3140 $459.55 $376.89 $308.47 $296.28 $258.18 $465.97 $382.15 $312.76 $297.0341 $468.18 $383.97 $314.26 $301.84 $263.02 $474.72 $389.32 $318.63 $302.6142 $476.45 $390.75 $319.81 $307.17 $267.67 $483.11 $396.20 $324.26 $307.9543 $487.96 $400.19 $327.53 $314.59 $274.13 $494.78 $405.77 $332.09 $315.3944 $502.34 $411.99 $337.19 $323.87 $282.22 $509.36 $417.73 $341.88 $324.6945 $519.25 $425.85 $348.53 $334.76 $291.71 $526.50 $431.78 $353.38 $335.6146 $539.38 $442.36 $362.05 $347.74 $303.02 $546.92 $448.53 $367.09 $348.6347 $562.04 $460.94 $377.26 $362.35 $315.75 $569.89 $467.37 $382.50 $363.2748 $587.93 $482.17 $394.63 $379.04 $330.29 $596.14 $488.90 $400.12 $380.0049 $613.46 $503.11 $411.77 $395.50 $344.64 $622.03 $510.13 $417.50 $396.5050 $642.22 $526.71 $431.08 $414.05 $360.80 $651.20 $534.05 $437.08 $415.1051 $670.63 $550.00 $450.15 $432.36 $376.76 $680.00 $557.67 $456.41 $433.4652 $701.92 $575.66 $471.15 $452.53 $394.33 $711.72 $583.69 $477.70 $453.6853 $733.56 $601.61 $492.39 $472.93 $412.11 $743.81 $610.00 $499.24 $474.1354 $767.72 $629.63 $515.32 $494.96 $431.30 $778.44 $638.41 $522.49 $496.2155 $801.88 $657.64 $538.25 $516.98 $450.49 $813.08 $666.81 $545.73 $518.2956 $838.92 $688.02 $563.11 $540.86 $471.30 $850.64 $697.61 $570.94 $542.2357 $876.32 $718.69 $588.21 $564.97 $492.31 $888.56 $728.71 $596.39 $566.4058 $916.23 $751.43 $615.00 $590.70 $514.73 $929.03 $761.90 $623.56 $592.2059 $936.01 $767.65 $628.28 $603.45 $525.85 $949.08 $778.35 $637.02 $604.9860 $975.92 $800.38 $655.07 $629.19 $548.27 $989.55 $811.54 $664.18 $630.7861 $1,010.44 $828.69 $678.24 $651.44 $567.66 $1,024.56 $840.24 $687.67 $653.0962 $1,033.10 $847.27 $693.45 $666.05 $580.39 $1,047.53 $859.08 $703.09 $667.7463 $1,061.50 $870.57 $712.51 $684.36 $596.35 $1,076.33 $882.71 $722.42 $686.1064 $1,078.76 $884.72 $724.10 $695.49 $606.05 $1,093.83 $897.06 $734.17 $697.25

65+ $1,078.76 $884.72 $724.10 $695.49 $606.05 $1,093.83 $897.06 $734.17 $697.25









Plan ID: 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001Exchange Plan?: Yes Yes Yes Yes Yes No No No No

Plan Adjusted Index From Unified Rating Template: $515.53 $422.80 $346.04 $332.37 $289.62 $522.73 $428.69 $350.85 $333.21Composite Age-Tobacco Use Factor / Composite Age Factor: 1.009 1.009 1.009 1.009 1.009 1.009 1.009 1.009 1.009

Plan Adjusted Index Rate times Composite Age-Tobacco Use Factor / Composite Age Factor: $520.07 $426.53 $349.09 $335.30 $292.18 $527.34 $432.47 $353.95 $336.15

COMPOSITES USING FINAL RATES

Composite Age 0-20Non-Tobacco User & Tobacco UserArea 1 $189.52 $155.43 $127.21 $122.19 $106.47 $192.17 $157.60 $128.98 $122.50Area 2 $196.54 $161.18 $131.92 $126.71 $110.41 $199.28 $163.43 $133.76 $127.03Area 4 $181.18 $148.59 $121.62 $116.81 $101.79 $183.72 $150.67 $123.31 $117.11Area 5 $190.28 $156.06 $127.72 $122.68 $106.90 $192.94 $158.23 $129.50 $122.99Area 5

Composite Age 21+Non-Tobacco UserArea 1 $563.63 $462.25 $378.33 $363.38 $316.65 $571.50 $468.69 $383.59 $364.30Area 2 $584.49 $479.35 $392.32 $376.82 $328.36 $592.65 $486.04 $397.78 $377.78Area 4 $538.83 $441.91 $361.68 $347.39 $302.71 $546.36 $448.07 $366.71 $348.27Area 5 $565.89 $464.10 $379.84 $364.83 $317.91 $573.79 $470.57 $385.12 $365.76

Tobacco UserArea 1 $676.36 $554.70 $453.99 $436.05 $379.97 $685.81 $562.43 $460.31 $437.16Area 2 $701.38 $575.22 $470.79 $452.19 $394.03 $711.18 $583.24 $477.34 $453.33Area 4 $646.60 $530.29 $434.02 $416.87 $363.26 $655.63 $537.69 $440.05 $417.92Area 5 $679.06 $556.92 $455.81 $437.80 $381.49 $688.55 $564.68 $462.15 $438.91

Composite Age 0-20Non-Tobacco User & Tobacco User $191.63 $157.16 $128.63 $123.55 $107.66 $194.31 $159.35 $130.42 $123.86

Composite Age 21+Non-Tobacco User $569.90 $467.39 $382.54 $367.42 $320.17 $577.86 $473.91 $387.86 $368.35Tobacco User $683.88 $560.87 $459.04 $440.91 $384.20 $693.44 $568.69 $465.43 $442.02

Composite Age 21+Non-Tobacco User & Tobacco User $575.20 $471.74 $386.09 $370.84 $323.15 $583.23 $478.31 $391.46 $371.78

Overall Composite $520.07 $426.53 $349.09 $335.30 $292.18 $527.34 $432.47 $353.95 $336.15


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 12 - COMPOSITE RATE CHECK

cecojl1

Text Box

1/1/2015 GHC INDIVIDUAL PLAN FILING--EXHIBIT 13

1 Product:

Group Health Cooperative Individual

and family Core3 Bronze Exchange





Exchange




Individual and Family Core H.S.A.

Direct2 Product ID: 80473WA079 80473WA078 80473WA081 80473WA083 80473WA0823 Metal: Gold Silver Bronze Bronze Catastrophic Gold Silver Bronze Bronze4 AV Metal Value: 0.812 0.711 0.619 0.602 0.598 0.812 0.711 0.619 0.602

5

Benefit Relativity Factor Used to Determine Avg. Rate: 0.867 0.710 0.580 0.557 0.484 0.880 0.720 0.588 0.558

6 Plan Type: HMO HMO HMO HMO HMO HMO HMO HMO HMO

7Plan Name:

Core3 Gold -15 Core3 Silver -15 Core3 Bronze - 15Core Bronze H.S.A. -

15 Core Basics Plus -15 Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15Core Bronze H.S.A. -

15

8 Plan ID : 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA08200019 Exchange Plan? Yes Yes Yes Yes Yes No No No No

10Projected 2014 Member Month5 13,440 118,152 28,560 27,840 636 32,016 35,232 79,368 79,368

11

Composite Benefit Relativity Factor Used to Determine Avg. Rate 0.657

12

Non-Essential Health Benefit % of Allowed Claims 0.013

13

Composite Benefit Relativity Factor Used to Determine Avg. Rate Reduced for Non-EHB 0.649

14Paid to Allowed Average Factor in Worksheet 1 0.649

From URRT Worksheet 1Index Rate for Projection Period $501.54Projected Allowed Experience Claims PMPM (w/applied credibility if applicable) $508.13Non-Essential Health Benefit % of Allowed Claims 1.3%


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 14 - PAID TO ALLOWED RATIOS


80473WA080


80473WA084

Item Description PMPM % Premium1 Administrative Charge - Fixed (Exhibit 8 - Line 10) $31.71 8.03%2 Administrative Charge - Variable ((Exhibit 8 - Line 13) $16.71 4.23%3 Commissions $6.62 1.68%4 Subtotal = URRT Admininstrative Cost $55.04 13.93%5 Premium Tax $7.90 2.00%6 WA Office of the Insurance Commissioner regulatory surcharge $0.37 0.093%7 ACA Carrier Fee [part of ACA] $3.94 1.00%8 WSHIP (Washington State Health Insurance Pool) assessment fee $1.19 0.30%9 Exchange Fees estimated collected for 2014 $1.91 0.48%

10 ACA (Section 4375 of ACA) PCORI fee – $2.28 Per member per year $0.19 0.05%11 Subtotal = URRT Taxes & Fees $15.50 3.92%12 Contribution to Surplus Load $7.90 2.00%13 Risk and Contingency Fee $3.95 1.00%14 Investment Income credit ($0.04) -0.01%15 Subtotal = URRT Profit & Risk $11.81 2.99%16 Grand Total $82.35 20.85%17 URRT Premium $394.99 100.00%18 URRT Paid Claims Check (18. - 17.) and Projected Loss Ratio $312.64 79.15%

Note: Figures in red indicate how the item is originally charged.


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 15 - URRT ADMINISTRATIVE COST,TAXES & FEES, PROFIT & RISK DETAIL

Individual PlanIndividual Plan Operating

Statutory ExpenseOperating Member Assessment

Year Expense Months PMPM Trend2010 $5,753,517 148,916 $38.642011 $6,771,009 152,982 $44.26 15%2012 $9,446,671 213,402 $44.27 0%2013 $11,317,312 270,003 $41.92 -5%

Average Three Year Trend: 3%Trend Used in Pricing: 3%

Note: Includes grandfathered and group conversion plans.

2013 Underwriting & Investment Exhibit Part 3 Analysis of Expenses InformationGHC GHO Total

Total General Admin Expenses $139,029,044 $107,936,566 $246,965,610Total Cost Containment Expenses $30,234,577 $15,602,592 $45,837,169Other Claim Adjustment Expenses $26,607,279 $7,192,630 $33,799,909Investment Expenses (Majority is Rent) $51,520,987 $721,535 $52,242,522Total $247,391,887 $131,453,323 $378,845,210State Premium Taxes $16,830,941 $17,623,917 $34,454,858Commissions $11,523,725 $19,899,487 $31,423,212Regulatory Authority Licenses and Fees $8,349,540 $7,299,125 $15,648,665Cost Containment and Other ClaimAdjustment Expenses as a Percent ofTotal Expenses Net of State PremiumTaxes and Reg. Licenses and Fees


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 16 - ADMINISTRATIVE COST TREND & VARIABLE COMPONENT

27.0% 26.3% 26.8%

Lewin Baseline ACA Elasticity Model

Figure 5- Change in Average Costs in the Non-Group Market under ACA in Washington in 2014

Membership Average Cost

Per MonthAverage

Age

Percent with Chronic

ConditionCurrent High Risk 5,076 $3,115 49 100.0%Current Other Non-Group 344,620 $314 35 19.5%Leave Non-Group 57,260 $378 38 22.2%

In Exchange High Risk 4,265 $2,167 48 100.0%In Exchange Other 129,821 $273 34 20.4%Outside Exchange 158,349 $333 34 18.3%Leave Other Coverage to take Non-Group

Employer 2-50 35,857 $573 34 24.7%Employer 51-100 4,527 $631 35 28.7%Employer 101+ 53,720 $849 33 33.4%

Medicaid/CHIP 25 $538 8 0.0% Uninsured 278,719 $314 34 24.1%Non-Group under ACA 665,284 $357 34 23.3%Elasticity Model - Lewin Baseline ACA model

Percent of Market Previously Uninsured 41.9%Morbidity change in Non-Group market 13.7%


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 17 - POPULATION MORBIDITY

Retain Non-Group

Product:



Bronze Exchange

Group Health Cooperative I&F Core

H.S.A. Exchange



Exchange



Group Health Cooperative Individual and Family Core

H.S.A. DirectItem Product ID: 80473WA079 80473WA078 80473WA081 80473WA083 80473WA082

Metal: Gold Silver Bronze Bronze Catastrophic Gold Silver Bronze Bronzea Market Adjusted Index Rate PMPM $486.56 $486.56 $486.56 $486.56 $486.56 $486.56 $486.56 $486.56 $486.56b Index Rate Allowed Claims PMPM $501.54 $501.54 $501.54 $501.54 $501.54 $501.54 $501.54 $501.54 $501.54c Starting AV Value (AV Metal Value) 0.812 0.711 0.619 0.602 0.598 0.812 0.711 0.619 0.602d Catastrophic Plan Eligibility Impact 1.000 1.000 1.000 1.000 0.880 1.000 1.000 1.000 1.000e Demand Elasticity Adj. 1.070 1.000 0.937 0.925 0.922 1.070 1.000 0.937 0.925f Non-EHB Benefits 1.013 1.013 1.013 1.013 1.013 1.013 1.013 1.013 1.013

gAdjustment to Pediatric Dental Benefit (Remove from Exchange Plans, Leaner Benefit for HSA Direct Plan) 0.986 0.986 0.986 0.986 0.986 1.000 1.000 1.000 0.989

h Benefit Relativity Factor (= c x d x e x f x g) 0.867 0.710 0.580 0.557 0.484 0.880 0.720 0.588 0.558i Paid Claims (= b x h) $435.08 $356.14 $290.80 $279.17 $242.78 $441.21 $361.16 $294.90 $279.88j Non-EHB Benefits Claims PMPM $5.64 $4.62 $3.77 $3.62 $3.15 $5.72 $4.68 $3.82 $3.63k Reinsurance Premium PMPM $3.67 $3.67 $3.67 $3.67 $3.67 $3.67 $3.67 $3.67 $3.67l Total Admin, Taxes & Fees, Profit, R&C % of Premium 20.8% 20.8% 20.8% 20.8% 20.8% 20.8% 20.8% 20.8% 20.8%

m Reinsurance Recovery as a % of Premium 5.2% 5.2% 5.2% 5.2% 5.2% 5.2% 5.2% 5.2% 5.2%n Risk Adjustments (User Fee) $0.08 $0.08 $0.08 $0.08 $0.08 $0.08 $0.08 $0.08 $0.08o 2015 Average Premium Rate PMPM [= (i + k + n) / (1 - l + m)] $520.07 $426.53 $349.09 $335.30 $292.18 $527.34 $432.47 $353.95 $336.15

p Composite Age Factor / Composite Age-Tobacco Use Factor 0.991 0.991 0.991 0.991 0.991 0.991 0.991 0.991 0.991q URRT Plan Adjusted Index Rate $515.53 $422.80 $346.04 $332.37 $289.62 $522.73 $428.69 $350.85 $333.21r URRT AV Pricing Value (= q / Exchange Silver q value) 1.219 1.000 0.818 0.786 0.685 1.236 1.014 0.830 0.788

Plan Name:Core3 Gold -15 Core3 Silver -15 Core3 Bronze - 15

Core Bronze H.S.A. -15 Core Basics Plus -15 Core3 Gold -15 Core3 Silver -15 Core3 Bronze-15 Core Bronze H.S.A. -15

Plan ID : 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001*Catastrophic plan eligibility criteria adjustment removes the increase in population morbidity = 1/1.1367



80473WA084

GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 18 - PLAN ADJUSTED INDEX RATES


80473WA080

GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 19 - GEOGRAPHIC AREA FACTOR BUILD-UP

Inpatient percent of total claims 22.0%

Contractual Data

Rating Area

Total Days

TotalAllowed

Case Mix Adjustment

Case Mix Adjusted Allowed

Case Mix Adjusted Allowed Per Day

Adjusted Allowed per Day

Adjusted Allowed per day

relative to Area 1

Final Area

Factor*

Ratio Highest

to lowest Area 1 31,681 $174,855,048 1.54 $113,310,294 $3,577 $3,577 1.000 1.000Area 2 31,991 $154,026,051 1.15 $133,675,573 $4,179 $4,179 1.168 1.037 1.085Area 3 1.000Area 4 11,042 $44,273,269 1.40 $31,549,767 $2,857 $2,857 0.799 0.956Area 5 8,232 $35,091,918 1.17 $29,918,114 $3,634 $3,634 1.016 1.004

Data: Oct 2011 - Sep 2012; Paid through Dec 2012 Commercial only. Excludes selected special facilities which are utilizedby members statewide such as:

Harborview Medical CenterSeattle Children's Hospital


No Data/Not in Service Area

a2015 Projected Claims Before ACA Reinsurance and Risk Adjust. PMPM (from URRT) $329.53

b ACA Individual Reinsurance Recovery Percent 6.3%c 2012 GHC Individual Claims (from 2012 MLR Filing) $51,512,817

d2012 GHC Individual Quality Improvement Expenses (from 2012 MLR Filing) $1,312,699

e

2015 Projected Claims PMPM after ACA Reinsurance Recovery and Reduction for Cost of Quality Improvement [=a*(1-b)*(1+(d/c))] $316.76

f 2015 Projected Premium PMPM (from URRT) $394.99g Premium Tax PMPM $7.90

hWA Office of the Insurance Commissioner regulatory surcharge PMPM $0.37

i ACA Carrier Fee [Section 9010 of the ACA] PMPM $3.94

jWSHIP (Washington State Health Insurance Pool) assessment fee PMPM $1.19

k Exchange Fees estimated collected for 2015 PMPM $1.91l ACA (Section 4375 of ACA) PCORI fee PMPM $0.19

m ACA Reinsurance Fee PMPM $3.67

n

ACA Risk Adjustment User Fee PMPM [March 11, 2014 HHS Notice of Benefit and Payment Parameters for 2015 Final Rule;III(C)(2)(a)] $0.08

o2012 GHC Individual Community Benefit Expenditures (from 2012 MLR Filing) $1,204,220

p 2012 GHC Individual Revenue (from 2012 MLR Filing) $59,688,956q Profit & Risk Load PMPM (From URRT) $11.81

r2015 Estimated Federal Income Tax PMPM (0% Tax Rate) [=q*0] $0.00

s

2015 Projected Premium PMPM after Deductions for Taxes, Fees, Community Benefit Expenditures [=f-sum(g to n)-r-f*o/p] $367.77

t 2015 Projected MLR [=e/s] 86.1%


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 20 - PROJECTED MLR

Annual Claim Cost Band Consumers Cost

Annual Frequency

Total Annual Claim per

Unique Claimant

Catastrophic Amount Apply Coins

0 - 70000 17,165 49,810,230 0.991383 2,902 0 060001-75000 16 1,012,117 0.000936 62,476 0 0

75001-100000 44 3,754,174 0.002541 85,322 674,174 337,087100001-125000 26 2,868,646 0.001502 110,333 1,048,646 524,323125001-150000 9 1,175,899 0.000520 130,655 545,899 272,950150001-175000 22 3,309,256 0.001271 150,421 1,769,256 884,628175001-200000 7 1,281,850 0.000404 183,121 791,850 395,925200001-250000 9 2,011,835 0.000520 223,537 1,381,835 690,917250001-500000 11 3,581,726 0.000635 325,611 1,980,000 990,000500001-750000 3 1,743,745 0.000173 581,248 540,000 270,000

750001-1000000 1 870,833 0.000058 870,833 180,000 90,0001000000+ 1 1,154,493 0.000058 1,154,493 180,000 90,000

4,545,830 Total 17,314 72,574,805 6.3%

Attachment Point 70,000 Reinsurance Cap 250,000 Coinsurance Rate 50%


EXPECTED REINSURANCE AS A PERCENTAGE OF CLAIMSEXHIBIT 21 - REINSURANCE CALCULATION

GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILING

Year 20131 20142 20152

Total Assessment $84,543,448 $41,500,000 $37,000,000Percent Change from 2013 49% 44%Group Health PMPM Assessment $2.73 $1.34 $1.19

1. WSHIP December 2013 Unaudited Financial Results2. WSHIP 2014-2015 Cashflow Projection draft 04082014


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 22- WSHIP ASSESSMENT

Historical Assessments and Projections

Non-Essential Benefit Description Plan Name Plan ID Exchange Plan?

Is Non-EHB Benefit Covered in the Plan? Deductible Coinsurance Copay

Out-of-Pocket Max Limits

2015 Premium Cost for the Non-

EHB (PMPM)

Adult Vision Exam Core3 Gold -15 * 80473WA0800006 Yes Yes$600 Indiv /

$1,200 Family 0%

$10 Primary /

$30 Specialty

$4,500 Indiv / $9,000 Family

One Per Calendar

Year $7.74

Adult Vision Exam Core3 Silver -15 * 80473WA0800001 Yes Yes$1,250 Indiv / $2,500 Family 0%

$20 Primary /

$45 Specialty

$6,350 Indiv / $12,700 Family

One Per Calendar

Year $6.53

Adult Vision Exam Core3 Bronze - 15 ** 80473WA0790001 Yes Yes$5,200 Indiv /

$10,400 Family 40%$40

Primary

$6,350 Indiv / $12,700 Family

One Per Calendar

Year $5.53

Adult Vision Exam Core Bronze H.S.A. -15 80473WA0780001 Yes Yes$4,000 Indiv / $8,000 Family 20% None

$6,450 Indiv / $12,900 Family

One Per Calendar

Year $5.35

Adult Vision Exam Core Basics Plus -15 80473WA0810001 Yes Yes$6,600 Indiv /

$13,200 Family 0% None

$6,600 Indiv / $13,200 Family

One Per Calendar

Year $4.79

Adult Vision Exam Core3 Gold -15 * 80473WA0840002 No Yes$600 Indiv /

$1,200 Family 0%

$10 Primary /

$30 Specialty

$4,500 Indiv / $9,000 Family

One Per Calendar

Year $6.84

Adult Vision Exam Core3 Silver -15 * 80473WA0840001 No Yes$1,250 Indiv / $2,500 Family 0%

$20 Primary /

$45 Specialty

$6,350 Indiv / $12,700 Family

One Per Calendar

Year $5.61

Adult Vision Exam Core3 Bronze-15 ** 80473WA0830001 No Yes$5,200 Indiv /

$10,400 Family 40%$40

Primary

$6,350 Indiv / $12,700 Family

One Per Calendar

Year $4.59

Adult Vision Exam Core Bronze H.S.A. -15 80473WA0820001 No Yes$4,000 Indiv / $8,000 Family 20% None

$6,450 Indiv / $12,900 Family

One Per Calendar

Year $4.36* Core3 Gold and Core3 Silver plans have first three combined primary care and specialty care visits covered with a copay only. Deductible applies thereafter.** Core3 Bronze plan has first three primary care visits covered with a copay only. Deductible and coinsurance apply thereafter.

Non-Essential Benefit Description Plan Name Plan ID Exchange Plan?

Is Non-EHB Benefit Covered in the Plan? Deductible Coinsurance Copay

Out-of-Pocket Max Limits

2015 Premium Cost for the Non-

EHB (PMPM)

Elective Abortion Core3 Gold -15 * 80473WA0800006 Yes Yes $0.00 0% $0.00$4,500 Indiv / $9,000 Family None $1.00

Elective Abortion Core3 Silver -15 * 80473WA0800001 Yes Yes $0.00 0% $0.00

$6,350 Indiv / $12,700 Family None $1.00

Elective Abortion Core3 Bronze - 15 ** 80473WA0790001 Yes Yes $0.00 0% $0.00


Elective Abortion Core Bronze H.S.A. -15 80473WA0780001 Yes Yes$4,000 Indiv / $8,000 Family 0% $0.00


Elective Abortion Core Basics Plus -15 80473WA0810001 Yes Yes$6,600 Indiv /

$13,200 Family 0% $0.00



GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 23 - NON-ESSENTIAL HEALTH BENEFIT DETAIL

Plan Cost Sharing Requirement for the Non-EHB

Plan Cost Sharing Requirement for the Non-EHB

PMPMa 2015 Index Rate $501.54

b

Federal Reinsurance Program Adjustment PMPM (from URRT) ($16.97)

c

Risk Adjustment (User Fee) PMPM (From URRT) $0.08

dExchange User Fee Adjustment $1.91

e

2015 Market Adjusted Index Rate (sum of a through d) $486.56


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 24 -MARKET ADJUSTED INDEX RATE

2015 PlansProduct ID: 80473WA080 80473WA080 80473WA079 80473WA078 80473WA081 80473WA084 80473WA084 80473WA083 80473WA082Metal Level: Gold Silver Bronze Bronze Catastrophic Gold Silver Bronze Bronze



Plan ID: 80473WA0800006 80473WA0800001 80473WA0790001 80473WA0780001 80473WA0810001 80473WA0840002 80473WA0840001 80473WA0830001 80473WA0820001Exchange Plan?: Yes Yes Yes Yes Yes No No No No Composite

Age, Area Calibrated Plan Adjusted Index Rate (=Plan Adjusted Rate Index Rate Divided by Composite Age,Area Factor) $298.46 $244.78 $200.34 $192.42 $167.68 $302.63 $248.19 $203.12 $192.91 $226.68 Projected 2015 Member Mths 13,440 118,152 28,560 27,840 636 32,016 35,232 79,368 79,368

2014 Plans (Mapped to Closest 2015 Plans)Product ID: 80473WA055 80473WA055 80473WA068 80473WA068 80473WA054 80473WA066 80473WA066 80473WA067 80473WA067Metal Level: Gold Silver Bronze Bronze Catastrophic Gold Silver Bronze BronzePlan Name: Core Gold Core Silver Core Bronze Core Bronze Core Basics Plus Core3 Gold Core3 Silver HealthPays Bronze HealthPays BronzePlan ID: 80473WA0550007 80473WA0550003 80473WA0680002 80473WA0680002 80473WA0540001 80473WA0660002 80473WA0660001 80473WA0670001 80473WA0670001Exchange Plan?: Yes Yes Yes Yes Yes No No No No Composite

Age, Area Calibrated Plan Adjusted Index Rate (=Plan Adjusted Rate Index Rate Divided by Composite Age,Area Factor) $274.27 $219.62 $166.35 $166.35 $174.64 $284.30 $234.60 $176.33 $176.33 $203.77

Composite TotalRate Increase After Benefit Changes:

8.8% 11.5% 20.4% 15.7% -4.0% 6.4% 5.8% 15.2% 9.4% 11.2%


GROUP HEALTH COOPERATIVE 1/1/2015 INDIVIDUAL RATE FILINGEXHIBIT 25 - RATE INCREASE CALCULATION

HBE - 2015 GHC Plans, Individual Family

Plan Name Core Basics Plus Core Bronze HSA Core3 Bronze Core3 Silver Core3 Silver 73 (Variation) Core3 Silver 87 (Variation) Core3 Silver 94 (Variation) Core3 GoldMetal Level Catastrophic Bronze Bronze Silver Silver Silver Silver GoldPlan Type (PPO, POS, HMO, EPO, Indemnity) HMO HMO HMO HMO HMO HMO HMO HMOExchange Plan? Yes Yes Yes Yes Yes Yes Yes YesPlan ID 80473WA0810001 80473WA0780001 80473WA0790001 80473WA0800001 80473WA0800004 80473WA0800003 80473WA0800002 80473WA0800006Deductible $6,600 Indiv / $13,200 Family $4,000 Indiv / $8,000 Family $5,200 Indiv / $10,400 Family $1,250 Indiv / $2,500 Family $1,250 Indiv / $2,500 Family $300 Indiv / $600 Family $50 Indiv / $100 Family $600 Indiv / $1,200 FamilyCoinsurance 100% 80% 60% 70% 70% 90% 95% 80%

Out of Pocket Maximum $6,600 Indiv / $13,200 Family $6,450 Indiv / $12,900 Family $6,350 Indiv / $12,700 Family $6,350 Indiv / $12,700 Family $5,200 Indiv / $10,400 Family(per HHS, may change)

$2,250 Indiv / $4,500 Family(per HHS, may change)

$2,250 Indiv / $4,500 Family(per HHS, may change) $4,500 Indiv / $9,000 Family

Deductible Notes

Does not apply to preventive care or pediatric eye exam & glasses.

After deductible member pays nothing

Deductible does not apply to first 3 Primary Care visits

Does not apply to preventive care, or pediatric eye exam & glasses

Does not apply to preventive care, generic drugs, pediatric

eye exam & glasses, termination of pregnancy or

hospice care

First 3 Primary Care visits: $40 copay, NSD; then

deductible/coinsurance



hospice care

Deductible does not apply to first 3 visits



hospice care




hospice care




hospice care




hospice care


Emergency Room Care 100% 80% 60% $200 + 30% $200 + 30% $200 + 10% $200 + 5% $200 + 20%All Inpatient Hospital Services 100% 80% 60% 70% 70% 90% 95% 80%Office Visit Primary Care / Specialty $0 Primary / $0 Specialty 80% 60% $20 Primary / $45 Specialty $20 Primary / $45 Specialty $10 Primary / $30 Specialty $0 Primary / $5 Specialty $10 Primary / $30 SpecialtyMental/Behavioral Health & Sub Abuse Outpt Svcs $0 Primary / $0 Specialty 80% 60% $20 Primary / $45 Specialty $20 Primary / $45 Specialty $10 Primary / $30 Specialty $0 Primary / $5 Specialty $10 Primary / $30 SpecialtyOutpatient Rehabilitative (ST, OT, PT) $0 Primary / $0 Specialty 80% 60% $20 Primary / $45 Specialty $20 Primary / $45 Specialty $10 Primary / $30 Specialty $0 Primary / $5 Specialty $10 Primary / $30 SpecialtyPreventive Care / Screening / Immunization No charge No charge No charge No charge No charge No charge No charge No chargeLaboratory Outpatient and Professional Services 100% 80% 60% 70% 70% 90% 95% 80%X-rays and diagnostic imaging (CT, PET Scans, MRIs) 100% 80% 60% 70% 70% 90% 95% 80%Skilled Nursing Facility 100% 80% 60% 70% 70% 90% 95% 80%Outpatient Facility Fee 100% 80% 60% 70% 70% 90% 95% 80%Outpatient Surgery 100% 80% 60% 70% 70% 90% 95% 80%Drugs

Generics 100% 80% $10 $10 $10 $10 $7 $10 Preferred Brand & Specialty 100% 60% 60% 60% 60% 70% 90% 80%Non-Preferred Brand Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered

Drugs - mail orderGenerics 100% 85% $5 $5 $5 $5 $2 $5Preferred Brand & Specialty 100% 65% 65% 65% 65% 75% 95% 85%Non-Preferred Brand Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered

Drugs - oral chemotherapyGenerics 100% 80% 60% $45 $45 $30 $5 $30Preferred Brand & Specialty 100% 80% 60% $45 $45 $30 $5 $30Non-Preferred Brand Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered

Actuarial Value 59.8% 60.2% 61.9% 71.1% 72.6% 86.3% 94.5% 81.2%

Direct - 2015 GHC Plans, Individual and FamilyPlan Name Core Bronze HSA Core3 Bronze Core3 Silver Core3 GoldMetal Level Bronze Bronze Silver GoldPlan Type (PPO, POS, HMO, EPO, Indemnity) HMO HMO HMO HMOExchange Plan? No No No No Plan ID 80473WA0820001 80473WA0830001 80473WA0840001 80473WA0840002Deductible $4,000 Indiv / $8,000 Family $5,200 Indiv / $10,400 Family $1,250 Indiv / $2,500 Family $600 Indiv / $1,200 FamilyCoinsurance 80% 60% 70% 80%Out of Pocket Maximum $6,450 Indiv / $12,900 Family $6,350 Indiv / $12,700 Family $6,350 Indiv / $12,700 Family $4,500 Indiv / $9,000 Family

Deductible NotesDoes not apply to preventive care, class I pediatric dental or pediatric

eye exam & glasses

Does not apply to preventive care, generic drugs, pediatric dental, pediatric eye exam & glasses, or

hospice care

First 3 Primary Care visits: $40 copay, NSD; then

deductible/coinsurance


hospice care



hospice care


Emergency Room Care 80% 60% $200 + 30% $200 + 20%All Inpatient Hospital Services 80% 60% 70% 80%Office Visit Primary Care / Specialty 80% 60% $20 Primary / $45 Specialty $10 Primary / $30 SpecialtyMental/Behavioral Health & Sub Abuse Outpatient Svcs 80% 60% $20 Primary / $45 Specialty $10 Primary / $30 SpecialtyOutpatient Rehabilitative (ST, OT, PT) 80% 60% $20 Primary / $45 Specialty $10 Primary / $30 SpecialtyPreventive Care / Screening / Immunization No charge No charge No charge No chargeLaboratory Outpatient and Professional Services 80% 60% 70% 80%X-rays and diagnostic imaging (CT, PET Scans, MRIs) 80% 60% 70% 80%Skilled Nursing Facility 80% 60% 70% 80%Outpatient Facility Fee 80% 60% 70% 80%Outpatient Surgery 80% 60% 70% 80%Drugs

Generics 80% $10 $10 $10 Preferred Brand & Specialty 60% 60% 60% 80%Non-Preferred Brand Not covered Not covered Not covered Not covered

Drugs - mail orderGenerics 85% $5 $5 $5 Preferred Brand & Specialty 65% 65% 65% 85%Non-Preferred Brand Not covered Not covered Not covered Not covered

Drugs - oral chemotherapyGenerics 80% 60% $45 $30Preferred Brand & Specialty 80% 60% $45 $30 Non-Preferred Brand Not covered Not covered Not covered Not covered

Actuarial Value 60.2% 61.9% 71.1% 81.2%

Core Basics Plus - 15

80473WA0810001

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 ($) $6,600.00

Coinsurance (%, Insurer's Cost Share) 100.00%

OOP Maximum ($) $6,600.00

OOP Maximum if Separate ($)

Click Here for Important Instructions

Type of BenefitSubject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical

Emergency Room Services

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): 3

Output

Status/Error Messages: Calculation Successful.

Actuarial Value: 59.8%

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:2nd Tier Utilization:

1st Tier Utilization:

All

All

All

All

All

All

All

All

Core Bronze HSA - 15

80473WA0780001







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics

Preferred Brand Drugs 60%

Non-Preferred Brand Drugs 60%

Specialty Drugs (i.e. high-cost) 60%





# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Bronze


Tier 1 Tier 2




All

All

All

All

All

All

All

All

Core3 Bronze - 15

80473WA0790001







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical



Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) $40.00

Specialist Visit


Services$40.00


Rehabilitative Speech Therapy $40.00

Rehabilitative Occupational and Rehabilitative Physical Therapy$40.00







Drugs

Generics $10.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output



Metal Tier: Bronze


Tier 1 Tier 2




All

All

All

All

All

All

All

All

Core3 Silver - 15

80473WA0800001







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical

Emergency Room Services $200.00



Specialist Visit $45.00


Services$20.00










Drugs

Generics $10.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output



Metal Tier: Silver


Tier 1 Tier 2




All

All

All

All

All

All

All

All

Core3 Silver 73 - 15

80473WA0800004







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services$20.00










Drugs

Generics $10.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output

Status/Error Messages: CSR Level of 73% (200-250% FPL), Calculation Successful.


Metal Tier: Silver


Tier 1 Tier 2




All

All

All

All

All

All

All

All


80473WA0800003







Desired Metal Tier


Deductible ($) $300.00






Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services$10.00










Drugs

Generics $10.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output



Metal Tier: Gold


Tier 1 Tier 2




All

All

All

All

All

All

All

All


80473WA0800002







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services










Drugs

Generics $7.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output



Metal Tier: Platinum


Tier 1 Tier 2




All

All

All

All

All

All

All

All

Core3 Gold - 15

80473WA0800006







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services$10.00










Drugs

Generics $10.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output



Metal Tier: Gold


Tier 1 Tier 2




All

All

All

All

All

All

All

All

Core Bronze HSA - 15

80473WA0820001







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Bronze


Tier 1 Tier 2




All

All

All

All

All

All

All

All

Core3 Bronze - 15

80473WA0830001







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services$40.00










Drugs

Generics $10.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output



Metal Tier: Bronze


Tier 1 Tier 2




All

All

All

All

All

All

All

All

Core3 Silver - 15

80473WA0840001







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services$20.00










Drugs

Generics $10.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output



Metal Tier: Silver


Tier 1 Tier 2




All

All

All

All

All

All

All

All

Core3 Gold - 15

80473WA0840002







Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services$10.00










Drugs

Generics $10.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10): 3

Output



Metal Tier: Gold


Tier 1 Tier 2




All

All

All

All

All

All

All

All