Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Rate Manual NBH-280 (2015) PPO PA Rev2018, NBH-280 (2014) Rev2018

Revised Previous State Filing Number:NGLI-130907676Percent Rate Change Request:6

NBH-280 (2015) PPOPA rev 16 Rate Manual2018.pdf,

SERFF Tracking #: NGLI-131294611 State Tracking #: NGLI-131294611 Company Tracking #: 2018-19 STUDENT HEALTH FILING -RATE

State: Pennsylvania Filing Company: National Guardian Life Insurance Company

TOI/Sub-TOI: H22 Student Health Insurance/H22.000 Student Health Insurance

Product Name: Student Health Insurance

Project Name/Number: 2018-19 Student Health Filing - Rate/2018-19 Student Health Rate Filing

PDF Pipeline for SERFF Tracking Number NGLI-131294611 Generated 01/11/2018 01:42 PM

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

Rate Manual Explanation

Page 4 of the rate manual, labelled Experience Rating Formula, is a demonstration of how rates will be calculated for new and renewal schools. Much of this data comes from school specific information entered on page 2 and 3. The first section shows school specific premium and claims experience and gross rates, along with completion factors taken from page 12, based on the effective date of the current plan and the claims paid through date entered on page 2. Claims The estimated lives is the total premium divided by the gross rate, and the lives used for credibility are the estimated lives divided by the completion factor. Next we calculate a Pure Rate which is the complete claims divided by estimated lives, which is then adjusted by the product change factors detailed on page 3.In the following section we apply the trend factors as described in the actuarial memorandum and detailed on page 2. The permissible loss ratio is for demonstration purposes and is defined below as Retention%. The calculation of the Gross Rate for a given year, P), is as follows:

𝐶𝑙𝑎𝑖𝑚𝑠 + 𝑄𝐼𝐸𝑝𝑝 + 𝑃𝐶𝑂𝑅𝐼𝑝𝑝

𝑅𝑒𝑡𝑒𝑛𝑡𝑖𝑜𝑛%(1 − 𝑃𝑟𝑒𝑚𝑖𝑢𝑚 𝑇𝑎𝑥 − 𝐻𝑒𝑎𝑙𝑡ℎ 𝐼𝑛𝑠𝑢𝑟𝑒𝑟 𝐹𝑒𝑒 −𝑄𝐼𝐸%

𝑅𝑒𝑡𝑒𝑛𝑡𝑖𝑜𝑛%)

Definitions:Claims – The Pure Rate (N)QIEpp – Quality improvement expenses per personPCORIpp – PCORI fees per personRetention% - The sum of all Percentage expenses, such as TPA, Quality improvement (on a % basis), Carrier fee, and profit margin (all listed on page 2)Premium Tax and Health Insurer Fee are self-explanatory, and are expressed as a percent of premium.

Next, we apply weights for each experience year and arrive at a weighted gross rate for the rating period (R). We then apply a pooling charge depending on the pooling level chosen. The pooling charges are laid out on page 15. Rows U and V are for demonstration purposes only. The manual rate is the rate calculated for the current plan using the rate model discussed below.

The plan designs entered on page 3 are used to generate plan change factors shown on the bottom of the page. The cost sharing options are run through pages 7 and 8 for non-drug and drug benefits, respectively. The details of the calculations on these pages are defined on the page, and are based on the model in the textbook, Group Insurance ed. Bluhm. The factors for deductibles and maximums used in the model are shown on pages 16 and 17. Assumptions for copay adjustments are listed on page 9. In general, we start at the total assumed allowed amount per person, remove the costs for copay benefits, then apply deductible and coinsurance factors. Seperately (L to AA) we make adjustments for copays and add those net amounts back in for a total claim cost (AE). Below are additional adjustments to copay benefits if deductibles and coinsurance also apply. Then this claims cost is used on page 10 where rating area factors (pp 18-25) and Network factors (page 14) applied. These are discussed in more detail on the memorandum.The credibility formula used in X is shown on page 15. The credibility weighted rate is the standard formula Exp Rate * Zc + Manual Rate * (1-Zc), where Zc is the credibility factor. The network differential (Z) is the proposed network factor divided by the current network factor. This is multiplied by the credibility weighted rate to arrive at the final proposed rate for the current plan.

1

Retrospective Premium Agreement

Optional for schools with greater than $2 million in annual premium

In the event the Policy Year incurred Loss Ratio is below XX percent (XX%) (Target Loss Ratio), Contractor shall pay the difference between the incurred Loss Ratio and XX% (Earned Premium * (XX% -Incurred Loss Ratio)) to the University, up to a maximum of X% of Premium. Such payment shall be made within 11 months after the last day of the policy period. This payment will be used by the University on behalf of the students for health care or similar services.

For example:

Earned Premium - $3,000,000Target Loss ratio - 72%Incurred Loss Ratio - 67%

Target - Incurred Loss ratio - 72%-67% = 5%Minimum of 3% & 5% = 3%

Payment due to school - 3% * $3,000,000 = $90,000

Undergraduate Plan: Graduate Plan: International Plan:

Name of School:

City: State: Zip Code: Commission: 2.50%

IPEDS ID: County: TPA/MGU: 0.00% See Plan Design & History Tab

Number of All Students: Effective Date: Premium Tax: #N/A Exp Mos

Number of UG Students: New/Renewal: QIE 0.00% 2014-2015: 1.000 36

Full-time Enrollment %: Policy Number: Carrier: 13.50% 2015-2016: 1.000 24

Number of Eligible Students: - Carrier: Profit Margin: 4.00% 2016-2017: 1.237 12

Participation %: #DIV/0! Pooling Max: Total Expenses: 20.00% 2017-2018:

Total PLR: 80.00%

Incumbent Carrier:

Incumbent Producer:

Incumbent Claim Payor: Rate History Years => 2014-2015 2015-2016 2016-2017 2017-2018

NGL/CT Producer: Agent Number: Student

NGL/CT Claim Payor: Spouse

Each Child

Enrollment Process: Child(ren)

Full-time/Part Time

Benefit Period: Policy Term Prior Years => 2014-2015 2015-2016 2016-2017 2017-2018

AV Calculator % (Proposed): Student NA #DIV/0! #DIV/0! #DIV/0!

Notes: Spouse NA #DIV/0! #DIV/0! #DIV/0!

Each Child NA #DIV/0! #DIV/0! #DIV/0!

Child(ren) NA #DIV/0! #DIV/0! #DIV/0!

Experience Years => 2014-2015 2015-2016 2016-2017 2017-2018

Gross Premium:

Paid Claims:

Number of Insured: - - - -

Large Claims : - - - -

Network :

On Call: N Rate: -$

Future Health: N Rate: -$

College Navigator Link http://nces.ed.gov/collegenavigator/?q=florida+a%26m&s=all&id=

Pooling Point $100,000

Total -$ -$ -$ -$ -$ -$ -$ -$

Claims 2014-2015 Pooled 2015-2016 Pooled 2016-2017 Pooled 2017-2018 Pooled

1 0 0 0 0

2 0 0 0 0

3 0 0 0 0

4 0 0 0 0

5 0 0 0 0

6 0 0 0 0

7 0 0 0 0

8 0 0 0 0

9 0 0 0 0

10 0 0 0 0

11 0 0 0 0

12 0 0 0 0

13 0 0 0 0

14 0 0 0 0

15 0 0 0 0

16 0 0 0 0

17 0 0 0 0

18 0 0 0 0

19 0 0 0 0

20 0 0 0 0

Premium/Claims Experience

Metal Tier:

2018-2019 Rate Calculation - Information Sheet - (Complete All Shaded Areas)

Rate History

PPO/Non-PPO:

Current PPO Network:

Completion Factors

Claims Paid Through Date:

Rates/Rate History Term of Coverage (ie. Annual):

Rate Adjustment Factor/Prior Years

Permissable Loss Ratio (PLR) Calculation Assumptions

Large Claims

100,000$

Proposed PPO Network:

3

Enter Census and Division Covered Sports Male Female

Division Archery

Badminton

Band

Baseball

Basketball

Bowling

Boxing

Cheerleading

Cheerleading (Mascot)

Coaches/Trainers

Crew/Rowing

Cross Country

Cycling

Dance

Drill Team

Equestrian

Fencing

Field Hockey

Football - Fall

Football - Spring

Football - Sprint

Football - Flag

Frisbee

Golf

Gymnastics

Handball/Racquettball

Ice Hockey

Lacrosse

Martial Arts

Rifle

Rodeo

Rugby

Sailing

Skiing - Alpine/Jumping

Skiing - Cross Country

Snowboarding

Soccer

Softball

Squash

Student Managers/Trainers

Surfing

Swimming/Diving

Tennis

Track/Field - Female

Track/Field - Male

Visitng Recruits

Volleyball

Volleyball - Beach (Sand)

Water Polo

Wrestling

Other

Total - -

Total All Sports -

Actual Net Claim Rates

Class Male Female

I -$ -$

II -$ -$

III -$ -$

IV -$ -$

V -$ -$

Covered SportsMale Female Class Male Female Total

Archery - - V - - -

Badminton - - V - - -

Band - - V - - -

Baseball - - III - - -

Basketball - - II - - -

Bowling - - V - - -

Boxing - - II - - -

Cheerleading - - III - - -

Cheerleading (Mascot)- - III - - -

Coaches/Trainers - - V - - -

Crew/Rowing - - V - - -

Cross Country - - V - - -

Cycling - - V - - -

Dance - - V - - -

Drill Team - - V - - -

Equestrian - - V - - -

Fencing - - V - - -

Field Hockey - - IV - - -

Football - Fall - - I - - -

Football - Spring - - II - - -

Football - Sprint - - II - - -

Football - Flag - - ii - - -

Frisbee - - v - - -

Golf - - v - - -

Gymnastics - - v - - -

Handball/Racquettball- - v - - -

Ice Hockey - - II - - -

Lacrosse - - III - - -

Martial Arts - - III - - -

Rifle - - V - - -

Rodeo - - II - - -

Rugby - - II - - -

Sailing - - V - - -

Skiing - Alpine/Jumping- - II - - -

Skiing - Cross Country- - V - - -

Snowboarding - - II - - -

Soccer - - II - - -

Softball - - III - - -

Squash - - V - - -

Student Managers/Trainers- - V - - -

Surfing - - V - - -

Swimming/Diving- - V - - -

Tennis - - V - - -

Track/Field - Female- - V - - -

Track/Field - Male- - IV - - -

Visitng Recruits - - V - - -

Volleyball - - III - - -

Volleyball - Beach (Sand)- - III - - -

Water Polo - - III - - -

Wrestling - - II - - -

Other - - v - - -

Total -

Total All Sports Per Person 0

FALSE FALSE FALSE FALSE

Current Plan History Proposed

Plan Design 2017-2018 2014-2015 2015-2016 2016-2017 2018-2019

Plan Maximum: Unlimited

Deductible:

Network:

Non-Network:

Co-insurance:

Network:

Non-Network:

Out-of-Pocket Maximum:

Network:

Non-Network:

Prescription Drug (Rx): D C D C D C D C D C

Generic Copay:

Brand Copay:

Non-Preferred Brand Copay:

Specialty Copay:

Deductible:

Co-insurance:

OOP Max

Co-pays: D C D C D C D C D C

Dr Office Visits (PCP):

Dr Office Visits (Specialist):

OP Visits (Mental /Sub. Abuse):

Emergency Room:

Urgent Care:

Inpatient:

Consultant:

Therapies (PT, ST, OT):

Diag. X-ray:

Lab:

Home Health:

OP Surgery:

Sports Covered

Transgender Covered

Claim Cost $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44

Plan Factor 1.000 1.000 1.000 1.000 1.000

Same Same Same Same

6

EXPERIENCE RATING FORMULA

EXAMPLE CALCULATION BASED ON SAMPLE DATA SHOWN/ASSUMED

School: 0

Claims as of: 1/0/1900

Runout 0.0

New/Renwal $0

Pooling Point Assumed: $100,000

2014 2015 2016 2017

A Premium............................................. $0 $0 $0 $0

B Claims Paid to Date............................... $0 $0 $0 $0

C Projection Factor.................................. 1.000 1.000 1.237 0.000

D Ultimate Claims............................................ $0 $0 $0 $0

E Loss Ratio w/o Large Claims..............................................

Total Loss Ratio

F Gross Rate.................................. Total - - - -

G …….est lives…………………………. 0 0 0 0 0

G2 Lives For Credibility 0 0 0 0 0

H Pure Rate..........................................

I Product Change Factor....................... 1.00 1.00 1.00 1.00

J As is Product Pure Rate......................

Annual Increase.................

K Inflation/Cost Shift............................. 5.3% 4.5% 5.3% 6.0%

L Trend Factor Applied............................ 1.228 1.166 1.116 1.060

M Network Factor #N/A #N/A #N/A #N/A

For as is Product:

N Pure Rate................................. $0 $0 $0 $0

O Permissable Loss Ratio...................

P Gross Rate...................................... -$ -$ -$ -$

Q Weight..................................…#N/A #N/A #N/A #N/A #N/A

R Gross Rate Before Pooling......................... $0

S Pooling Charge 7.0% based on Plan Maximum and Pooling Point from above

T Gross Rate Needed $0

U Comm: 2.5%

V CT Administration: 20.0%

W Manual Rate $1,747.00

X Credibility Factor 0% based on avg # students and # months experience

Y Credibility Weighted Rate $1,747.00 01/02/18

Z Network differential #N/A

AA Network differential adjusted Rate #N/A

Rate Change Existing #N/A

Rate Change Proposed #N/A

NBH-280 (2015) PPO PA rev 16 Rate Manual 2018 7

Proposed

School Name: 0 Plan Design 2018-2019

Prepared by: Company: Plan Maximum: -$

Producer: 0 Deductible:

Date: Network: -$

Claim Payor: 0 Non-Network: -$

Co-insurance:

Efffective Date: 01/00/1900 New/Renewal: 0 Approved by: Company: Network: 0%

Non-Network: 0%

Expenses: Date: Out-of-Pocket Maximum:

Commissions: 2.50% Network: -$

Claim Payor: 0.00% Comments/Notes: Non-Network: -$

Premium Tax: #N/A Prescription Drug (Rx): D C

PPACCA % Fees: 2.75% Generic Copay: -$ 0 0

QIE 0.00% Brand Copay: -$ 0 0

Carrier: 13.50% Non-Preferred Brand Copay: -$ 0 0

Gross Margin: 4.00% Specialty Copay: -$ 0 0

Total Expenses: #N/A Deductible: -$

TLR: #N/A Co-insurance: 0%

OOP Max -$

Co-pays: D C

Current Plan Design Rates Dr Office Visits (PCP): -$ 0 0

Dr Office Visits (Specialist): -$ 0 0

OP Visits (Mental /Sub. Abuse): -$ 0 0

Student Spouse Child Child(ren) Student Emergency Room: -$ 0 0

Annual -$ -$ -$ -$ #N/A Urgent Care: -$ 0 0

Inpatient: -$ 0 0

Additional Annual Costs per Insured Consultant: -$ 0 0

Therapies (PT, ST, OT): -$ 0 0

2018-2019 Rate Adjustment: #N/A Diag. X-ray: -$ 0 0

Lab: -$ 0 0

AV Calculator Proposed Plan: 0.00% Home Health: -$ 0 0

Metal Level Proposed Plan: 0 OP Surgery: -$ 0 0

Sports Covered -$ 0 0

2018-2019 Proposed Plan Factor: 1 Transgender Covered -$ 0 0

2018-2019 Proposed Plan Rate: #N/A

2017-2018 Proposed Plan Rate Increase: #N/A

2017-2018 Proposed First Time Buyer Plan Rate: 1,747$

Fees allolcated outside of MLR: Proposed Network 0

PCORI Fee 2.32$

PPACA Reinsurance Fee

Health Insurer Fee #N/A

Premium Tax: #N/A

Travel Assistance -$

Future Health -$

Total Fees Allocated Outside of MLR: #N/A

NGL/CTProposed Underwriting

2017-2018 Rates 2018-2019 Rates

NBH-280 (2015) PPO PA rev 16 Rate Manual 2018 8

EXPERIENCE RATING FORMULA DEFINITIONS

A) Premium – Annual premium collected

B) Claims Paid to Date – Annual Claims paid for the school year to the

“Claims as of” date.

C) Projection Factor – Factor to bring paid claims to incurred claims for

the school year. Based on internal paid claims data and updated

monthly.

D) Ultimate Claims – B*C

E) Loss ratio – D/A

F) Gross rate – Annual premium rate per student.

G) Estimated lives – A/F

G2) Lives / Completion Factor

H) Pure Rate – D/G, annual claims per student

I) Product Change Factor – Factor to account for actuarial value of a

change in benefits.

J) H*I

K) Inflation/Cost Shift – Medical cost inflation factor based on industry

expectations.

L) Percent Applicable – Some plans have limits or caps on benefits and

therefore a full inflation factor is not appropriate. This percentage

accounts for how much of the trend factor to use.

M) Trend Factor Applied – 1+(K*L)t * 1+(K*L)t-1…..

N) For as is Product Pure Rate - J*M

O) Permissible Loss Ratio – 1-U-V.

P) Gross Rate – (N+QIEpp+FEDpp)/(O(1-PTAX-HIF-QIE%/O))

Q) Weight – The weight given to each experience period. The total

weights must add to one.

R) Gross Rate Before Pooling - t

n

t

t QP *1

S) Pooling Charge – From Pooling Charge Table

T) Gross Rate Needed – R *(1+S)

U) Commission % - Commissions as a percent of premium

V) CT Administrative charge – The percent of premium allocated to

Commercial Travelers for Administration , Profit and Contingencies

W) Manual Rate – Final Rate Derived by rating manual for the plan

benefits

X) Credibility Factor – Derived from Credibility Table

Y) Credibility Weighted Rate – T*X+W*(1-X)

Z) Network factor (projected)/Network factor (previous)

AA) Y * Network differential

9

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONT

Apply Apply

Plan Design Copays Deductible Coinsurance

Annual Max Unlimited Dr Office Visits (PCP): $0 Blue font and this color shading indicates a user input for the rating model

Deductible $100 Dr Office Visits (Specialist): $0

Coinsurance 80% OP Visits (Mental /Sub. Abuse): $0

Out of Pocket Max $6,000 Emergency Room: $0

Urgent Care: $0

Inpatient: $0

enter $0 if none Consultant: $0

Therapies (PT, ST, OT): $0

Diag. X-ray: $0

Lab: $0

Home Health: $0

OP Surgery: $0

Calculation $1,408.51 Definitions

A Starting Claims Cost w/o copays $1,382.35 A Total Allowed Charges for all benefits, minus AC (Gross) minus AD plus AC (net applicable)

B Annual Max Unlimited B Annual benefit maximum for the plan

C Value of Max $1,382.35 C The value of claims under the annual maximum

D Deductible 100$ D Deductible for the plan under which no benefit is paid

E Value of Deductible 51.27$ E The value of claims under the deductible (Ded Factor page '% of Total' column * A)

F Coinsurance 80% F Percentage of benefits paid by the plan once deductible is met

G Out of Pocket Max 6,000$ G Maximum dollar value of coinsurance paid by the insured

H OOP Allowed Charges 30,100$ H G/(1-F)+D, The level of allowed charges over which the plan pays 100%

I Value of Claims Over OOP $288.60 I Value of claims for which the plan pays 100%

J Value of OOP 1,093.74$ J A-I, The value of claims under the Out of Pocket Max

K Net Claims Cost 1,122.58$ K (J-E)*F+(C-J)*1, Total value of benefits paid by the plan assuming no copays

Gross Net Copay Value

L Dr Office Visits (PCP): $0.00 $0.00 $0.00

M Dr Office Visits (Specialist): $0.00 $0.00 $0.00

N OP Visits (Mental /Sub. Abuse): $0.00 $0.00 $0.00

O Emergency Room: $0.00 $0.00 $0.00

P Urgent Care: $0.00 $0.00 $0.00

Q Inpatient: $0.00 $0.00 $0.00

R Consultant: $0.00 $0.00 $0.00

S Therapies (PT, ST, OT): $0.00 $0.00 $0.00

T Diag. X-ray: $0.00 $0.00 $0.00

Ta Lab: $0.00 $0.00 $0.00

U Home Health: $0.00 $0.00 $0.00

V OP Surgery: $0.00 $0.00 $0.00

X Generic:Y Brand:

Z Non-Preferred Brand:

AA Specilaty:

AB Total Copay Cost PMPY $0.00 $0.00 $0.00 AB Sum of net and gross copay values

AC Net Value of Copays $0.00 AC Net Value of Benefits subject to copays

AD Additional Benefits not subject to Cost Sharing 26.17$ AD Value of Preventive Benefits

AE Total Claims Cost 1,148.75$ AE K*AA+Y+Z-X (Copay Value)

Ded/Coins Coins Only Deductible Only

Gross PMPY Net PMPY Net Applicable Adjustment Adjustment

Dr Office Visits (PCP): 43.04 43.04 -$ -$ -$

Dr Office Visits (Specialist): 36.66 36.66 -$ -$ -$

OP Visits (Mental /Sub. Abuse): 19.22 19.22 -$ -$ -$

Emergency Room: 135.80 135.80 -$ -$ -$

Urgent Care: 4.22 4.22 -$ -$ -$

Inpatient: 107.97 107.97 -$ -$ -$

Consultant: 6.46 6.46 -$ -$ -$

Therapies (PT, ST, OT): 24.91 24.91 -$ -$ -$

Diag. X-ray: 80.75 80.75 -$ -$ -$

Lab: 97.66 97.66 -$ -$ -$

Home Health: 2.50 2.50 -$ -$ -$

OP Surgery: 85.98 85.98 -$ -$ -$

AF Total $547.51 $645.17 $0.00 $0.00 $0.00

Benefits with no Cost Sharing Net PMPY

AGPreventive 26.17$

L-

AANet and Gross values of benefits with copays attached

10

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTPRESCRIPTION DRUGS Apply Apply

Plan Design Copays Deductible Coinsurance

Annual Max Unlimited Blue font and this color shading indicates a user input for the rating model

Deductible $0

Coinsurance $0 Drug-Generic $0

Out of Pocket Max $0 Drug-Brand $0

Drug-non pref Brand $0

Drug-Spec $0

enter $0 if none

ADCalculation $241.48 Definitions

A Starting Claims Cost w/o copays $5.16 A Total Allowed Charges for non-copay benefits (AD-Z(1)-AC+Z(3))

B Annual Max Unlimited B Annual benefit maximum for the plan

C Value of Max $5.16 C The value of claims under the annual maximum

D Deductible -$ D Deductible for the plan under which no benefit is paid

E Value of Deductible -$ E The value of claims under the deductible

F Coinsurance 0% F Percentage of benefits paid by the plan once deductible is met

G Out of Pocket Max -$ G Maximum dollar value of coinsurance paid by the insured

H OOP Allowed Charges -$ H G/(1-F)+D, The level of allowed charges over which the plan pays 100%

I Value of Claims Over OOP $24.69 I Value of claims for which the plan pays 100%

J Value of OOP -$ J A-I, The value of claims under the Out of Pocket Max

K Net Claims Cost 5.16$ K (J-E)*F+(C-J)*1, Total value of benefits paid by the plan assuming no copays

Gross Net Copay Value

L ER PMPY

M Visit PMPY

N Drug-Generic $0.00 $0.00 $0.00

O Drug-Brand $0.00 $0.00 $0.00

P Drug-non pref Brand $0.00 $0.00 $0.00

Q Drug-Spec $0.00 $0.00 $0.00

R Outpatient Surgery PMPY

S Physical Therapy PMPY

T Diagnostic X-Ray PMPY

U Home Health PMPY

V Inpatient PMPY

W Consulting Physician PMPY

X Total Copay Cost PMPY $0.00 $0.00 $0.00 X Sum of net and gross copay values

Y Net Value of Copays $236.32 Y Net Value of Benefits subject to copays

Z Additional Benefits -$ Z

AA Product Change Factor 1.0000 AA Product of all benefit factors reflecting changes in benefits from rate manual

AB Total Claims Cost 241.48$ AB K*AA+Y+Z-X (Copay Value)

1 2 Ded/Coins Coins Only Deductible Only

Gross PMPY Net PMPY Net Applicable Adjustment Adjustment

Drug-Generic $42.92 $42.92 -$ -$ -$

Drug-Brand $141.17 $141.17 -$ -$ -$

Drug-non pref Brand $26.95 $26.95 -$ -$ -$

Drug-Spec $25.28 $25.28 -$ -$ -$

Z Total $236.32 $236.32 $0.00 $0.00 $0.00

Copay Value $0.00

benefits with no Cost Sharing Net PMPY

AC

L-W Net and Gross values of benefits with copays attached

11

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONT

COPAY DATA

Average Average

Benefit Claims/personallowed/claim pmpm

AMB SURG CENTER 0.0026 5,635.70$ 14.80$

AMBULANCE 0.0093 1,345.59$ 12.57$

DME/SUPPLIES 0.0373 401.22$ 14.97$

Generic 1.35 31.85 42.92

Pref Brand 0.88 161.28 141.17

Non Pref Brand 0.10 271.92 26.95

Specialty 0.01 2,739.56 25.28 $236.32

HOSPITAL - ER 0.0520 2,612.25$ 135.80$

HOSPITAL - INP ALC/SUB 0.0002 5,313.16$ 0.94$

HOSPITAL - INP MATERNITY 0.0011 7,781.10$ 8.19$

HOSPITAL - INP MH 0.0012 4,681.05$ 5.56$

HOSPITAL - INP NEWBORN 0.0007 2,594.63$ 1.76$

HOSPITAL - INPATIENT 0.0079 11,957.52$ 94.22$

HOSPITAL - OUT ALC/SUB 0.0023 2,203.29$ 5.12$

HOSPITAL - OUT PSYCH 0.0043 1,120.80$ 4.79$

HOSPITAL - OUTPATIENT 0.0955 1,800.13$ 171.97$

INJECTIONS/DRUGS 0.0895 465.44$ 41.66$

OTHER 0.1939 802.57$ 155.60$

PATHOLOGY 1.4076 69.38$ 97.66$

PHYS - ALC/SUB 0.0140 120.67$ 1.69$

PHYS - CHIRO 0.0573 58.48$ 3.35$

PHYS - CONSULTS 0.0257 250.99$ 6.46$

PHYS - HOSP/ER VISITS 0.1569 523.21$ 82.07$

PHYS - IMMUN 0.0774 66.80$ 5.17$

PHYS - OTHER 0.9180 186.29$ 171.01$

PHYS - PREVENTIVE 0.1506 173.76$ 26.17$

PHYS - PSYCH 0.1170 149.88$ 17.53$

PHYS - SURG INP 0.0043 2,097.19$ 9.11$

PHYS - SURG OTHER 0.2543 426.23$ 108.38$

PT/OT 0.3742 66.58$ 24.91$

RADIOLOGY 0.2512 321.52$ 80.75$

URGENT CARE 0.0310 136.06$ 4.22$

PCP Visit 0.3676 117.08$ 43.04$

Spec Visit 0.3131 117.08$ 36.66$

Home Health 0.0050 500.00$ 2.50$

0.6807

12

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTManual Rate Calculation

Unlimited Annual Max Rating Area Factor

$100 Deductible 0

80% Coinsurance #N/A

$6,000 OOP Max Network

Assumed Copays 0

Dr Office Visits (PCP): $0 #N/A

Dr Office Visits (Specialist): $0

OP Visits (Mental /Sub. Abuse): $0

Emergency Room: $0

Urgent Care: $0

Inpatient: $0

Consultant: $0

Therapies (PT, ST, OT): $0

Diag. X-ray: $0

Home Health: $0

OP Surgery: $0

Drug-Generic $0

Drug-Brand $0

Drug-non pref Brand $0

Drug-Spec $0

Total Claims Cost (from Pricing Defs) $1,390.23

#N/A

#N/A

PPACA-Compliant Expenses 20.0%

QIE 0.00%

Additional Assessments Exempt from PPACA

State Premium Tax & Assesments #N/A

PPACA Annual Health Insurer (HI) Fee* 2.75%

Total Additional Assessments Exempt from PPACA #N/A

% of prem

+ PPACA Transitional Reins Fee (Per Life, Same All Classes)* $0.00 #N/A

+ PPACA PCORI Fee (Per Life, Same All Classes) $2.32 #N/A

Total Rate $2.32

Class Final Annual Rates # covered lives assumed

Student-Only #N/A 1

Geographic Adjusted Claim Costs

Geographic & Network Adjusted Claim Costs

13

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTADMINISTRATIVE EXPENSES

Ranges

Commission: 0-3%

Claim Payor/TPA: 5-12%

QIE 0-2%

Carrier: 3-6%

Profit Margin: 3-5%

Ranges are determined by relationship with claim payor/TPA and what is charged for their services

The total administrative expense/profit will not exceed the amount constrained by the Federal

Minimum Loss Ratio according to the following formula

(Claims+QIE Expenses)/(Premium-Taxes and Fees)

14

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTCOMPLETION FACTORS Used unless school specific experience is available and credible

Use for 2017-2018 Policy

Month CHP Healthsmart HOA Table 3

2 38.965 125.740 221.549 2 221.549

3 14.906 25.002 26.143 3 26.143

4 8.337 12.193 13.316 4 13.316

5 4.868 7.076 7.576 5 7.576

6 3.659 4.804 4.740 6 4.74

7 2.826 3.504 3.350 7 3.35

8 2.223 2.707 2.501 8 2.501

9 1.847 2.204 1.965 9 1.965

10 1.577 1.807 1.624 10 1.624

11 1.371 1.566 1.388 11 1.388

12 1.218 1.390 1.237 12 1.237

13 1.117 1.198 1.110 13 1.11

14 1.076 1.135 1.069 14 1.069

15 1.053 1.105 1.055 15 1.055

16 1.045 1.090 1.038 16 1.038

17 1.041 1.086 1.029 17 1.029

18 1.036 1.071 1.018 18 1.018

19 1.029 1.060 1.014 19 1.014

20 1.027 1.041 1.006 20 1.006

21 1.026 1.035 1.003 21 1.003

22 1.025 1.025 1.002 22 1.002

23 1.024 1.016 1.001 23 1.001

24 1.024 1.014 1.000 24 1

25 1.013 1.014 1.000 25 1

26 1.009 1.007 1.000 26 1

27 1.008 1.007 1.000 27 1

28 1.006 1.007 1.000 28 1

29 1.006 1.006 1.000 29 1

30 1.001 1.006 1.000 30 1

31 1.001 1.006 1.000 31 1

32 1.001 1.006 1.000 32 1

33 1.000 1.006 1.000 33 1

34 1.000 1.000 1.000 34 1

35 1.000 1.000 1.000 35 1

36 1.000 1.000 1.000 36 1

37 1.000 1.000 1.000 37 1

38 1.0000 1.000 1.000 38 1

39 1.0000 1.000 1.000 39 1

40 1.0000 1.000 1.000 40 1

41 1.0000 1.000 1.000 41 1

42 1.0000 1.000 1.000 42 1

43 1.0000 1.000 1.000 43 1

44 1.0000 1.000 1.000 44 1

45 1.0000 1.000 1.000 45 1

46 1.0000 1.000 1.000 46 1

47 1.0000 1.000 1.000 47 1

48 1.0000 1.000 1.000 48 1

49 1.0000 1.000 1.000 49 1

50 1.0000 1.000 1.000 50 1

51 1.0000 1.000 1.000 51 1

52 1.0000 1.000 1.000 52 1

53 1.0000 1.000 1.000 53 1

54 1.0000 1.000 1.000 54 1

55 1.0000 1.000 1.000 55 1

56 1.0000 1.000 1.000 56 1

57 1.0000 1.000 1.000

58 1.0000 1.000 1.000

59 1.0000 1.000 1.000

60 1.0000 1.000 1.000

61 1.0000 1.000 1.000

62 1.0000 1.000 1.000

63 1.0000 1.000 1.000

64 1.0000 1.000 1.000

65 1.0000 1.000 1.000

66 1.0000 1.000 1.000

67 1.0000 1.000 1.000

68 1.0000 1.000 1.000

69 1.0000 1.000 1.000

70 1.0000 1.000 1.000

71 1.0000 1.000 1.000

72 1.0000

73 1.0000

74 1.0000

15

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTCTM Effective Premium Tax Rates By State

Effective Premium

State State Tax Rate

AL Alabama 1.600% (1.6% generally, 0.5% for group policies with less than 50 members)

AK Alaska 2.700%

AZ Arizona 2.000%

AR Arkansas 2.500%

CA California 2.350%

CO Colorado 2.000%

CT Connecticut 1.750%

DE Delaware 2.000%

DC District of Columbia 2.000%

FL Florida 1.750%

GA Georgia 2.250%

HI Hawaii 4.265%

ID Idaho 1.500%

IL Illinois 0.400%

IN Indiana 1.300%

IA Iowa 1.000%

KS Kansas 2.000%

KY Kentucky 1.500%

LA Louisiana 2.250%

ME Maine 2.000%

MD Maryland 2.000%

MA Massachusetts 2.000%

MI Michigan 1.250%

MN Minnesota 2.000%

MS Mississippi 3.000%

MO Missouri 2.000%

MT Montana 2.750%

NE Nebraska 1.000%

NV Nevada 3.500%

NH New Hampshire 2.000%

NJ New Jersey 1.050%

NM New Mexico 3.003%

NY New York 2.000%

NC North Carolina 1.900%

ND North Dakota 1.750%

OH Ohio 1.400%

OK Oklahoma 2.250%

OR Oregon 0.000%

PA Pennsylvania 2.000%

RI Rhode Island 2.000%

SC South Carolina 1.250%

SD South Dakota 2.500%

TN Tennessee 1.750%

TX Texas 2.750%

UT Utah 2.250%

VT Vermont 2.000%

VA Virginia 2.250%

WA Washington 2.000%

WV West Virginia 3.000%

WI Wisconsin 0.000%

WY Wyoming 0.750%

16

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONT

Current Proposed

#N/A Cigna 1

Other Other

#N/A #N/A

#N/A #N/A

#N/A

Current Experience Factor 0.692

Network adjustment Factor #N/A

NETWORK DISCOUNT FACTORS

State County code Cigna Magnacare First Health PHCS Multiplan Healthlink BCBS United Aetna

AL Other ALOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

AL Jefferson ALJefferson 0.48 0.80 0.68 0.76 0.69 0.48 0.48 0.48

AZ Maricopa AZMaricopa 0.375 0.604 0.719 0.731 0.69 0.38 0.38 0.38

AZ Pima AZPima 0.346 0.657 0.69 0.731 0.69 0.346 0.346 0.346

AZ Other AZOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

CA Los Angeles CALos Angeles 0.53 0.60 0.69 0.80 0.69 0.53 0.53 0.53

CA San Fransisco CASan Fransisco 0.60 0.69 0.71 0.80 0.69 0.60 0.60 0.60

CA Other CAOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

CO Other COOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

CT Other CTOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

DC Other DCOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

FL Volusia FLVolusia 0.48 0.68 1.00 0.80 0.69 0.48 0.48 0.48

FL Duval FLDuval 0.54 0.66 0.76 0.80 0.69 0.54 0.54 0.54

FL Miami-Dade FLMiami-Dade 0.45 0.74 0.70 0.80 0.69 0.45 0.45 0.45

FL Orange FLOrange 0.43 0.71 0.72 0.80 0.69 0.43 0.43 0.43

FL Other FLOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

HI Other HIOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

ID Other IDOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

IL Cook ILCook 0.48 0.73 0.68 0.80 0.69 0.48 0.48 0.48

IL Other ILOther 0.61 0.72 0.80 0.77 0.69 0.61 0.61 0.61

IN Marion INMarion 0.67 0.76 0.80 0.80 0.69 0.67 0.67 0.67

IN Other INOther 0.67 0.92 0.71 0.80 0.69 0.67 0.67 0.67

KS Other KSOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

LA E. Baton Rouge LAE. Baton Rouge 0.538 0.73 0.627 0.69 0.69 0.538 0.538 0.538

LA Orleans LAOrleans 0.473 0.71 0.689 0.69 0.69 0.473 0.473 0.473

LA Other LAOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

MA Berkshire MABerkshire 0.60 0.73 0.77 0.81 0.69 0.60 0.60 0.60

MA Franklin MAFranklin 0.60 0.73 0.77 0.81 0.69 0.60 0.60 0.60

MA Hampshire MAHampshire 0.60 0.73 0.77 0.81 0.69 0.60 0.60 0.60

MA Hampden MAHampden 0.60 0.73 0.77 0.81 0.69 0.60 0.60 0.60

MA Worcester MAWorcester 0.60 0.73 0.77 0.81 0.69 0.60 0.60 0.60

MA Other MAOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

MD Baltimore MDBaltimore 0.65 0.80 0.92 0.87 0.69 0.65 0.65 0.65

MD Other MDOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

MN Other MNOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

MN Hennepin MNHennepin 0.60 0.77 0.77 0.88 0.69 0.60 0.60 0.60

MN Olmsted MNOlmsted 0.98 1.00 0.96 0.88 0.69 0.98 0.98 0.98

MN Saint Louis MNSaint Louis 0.76 1.00 0.85 0.88 0.69 0.76 0.76 0.76

MN Hennepin MNHennepin 0.60 0.77 0.77 0.88 0.69 0.60 0.60 0.60

MN Olmsted MNOlmsted 0.97 1.00 0.96 0.88 0.69 0.97 0.97 0.97

MN Other MNOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

MO St. Louis MOSt. Louis 0.43 0.69 0.69 0.69 0.69 0.43 0.43 0.43

MO Boone MOBoone 0.71 0.65 0.67 0.74 0.69 0.71 0.71 0.71

MO Jackson MOJackson 0.50 0.69 0.69 0.69 0.69 0.50 0.50 0.50

MS Other MSOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

NC Mecklenburg NCMecklenburg 0.61 0.91 0.80 0.85 0.69 0.61 0.61 0.61

NC Wake NCWake 0.53 0.67 0.77 0.85 0.69 0.53 0.53 0.53

NC Durham NCDurham 0.53 0.67 0.77 0.85 0.69 0.53 0.53 0.53

NC Other NCOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

NE Other NEOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

NH Other NHOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

NJ Mercer NJMercer 0.47 0.76 0.65 0.76 0.69 0.47 0.47 0.47

NJ Hudson NJHudson 0.69 0.586 0.69 0.69 0.69 0.69 0.69 0.69 0.69

NJ Other NJOther 0.44 0.63 0.65 0.73 0.69 0.44 0.44 0.44

NV Clark NVClark 0.356 0.605 0.519 0.772 0.71 0.356 0.356 0.356

NV Other NVOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

NY Erie NYErie 0.61 0.69 0.69 0.69 0.76 0.69 0.61 0.61 0.61

NY Albany NYAlbany 0.48 0.75 0.69 0.69 0.79 0.69 0.48 0.48 0.48

NY New York NYNew York 0.51 0.53 0.69 0.69 0.72 0.69 0.51 0.51 0.51

NY Other NYOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

OH Hamilton OHHamilton 0.64 0.81 0.81 0.81 0.69 0.64 0.64 0.64

OH Cuyahoga OHCuyahoga 0.61 0.76 0.85 0.84 0.69 0.61 0.61 0.61

OH Lucas OHLucas 0.45 0.71 0.79 0.84 0.69 0.45 0.45 0.45

OH Other OHOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

OK Other OKOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

OR Other OROther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

PA Philadelphia PAPhiladelphia 0.57 0.73 0.73 1.00 0.69 0.57 0.57 0.57

PA Allegheny PAAllegheny 0.60 0.67 0.80 0.87 0.69 0.60 0.60 0.60

PA Other PAOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

RI Other RIOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

SC Charleston SCCharleston 0.61 0.75 0.76 0.83 0.69 0.61 0.61 0.61

SC Richland SCRichland 0.60 0.61 0.76 0.83 0.69 0.60 0.60 0.60

SC Other SCOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

TN Shelby TNShelby 0.52 0.85 0.64 0.79 0.69 0.36 0.36 0.36

TN Davidson TNDavidson 0.64 0.71 0.67 0.79 0.69 0.52 0.52 0.52

TN Other TNOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

TX Harris TXHarris 0.57 0.69 0.69 0.69 0.69 0.57 0.57 0.57

TX Other TXOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

UT Other UTOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

VA Other VAOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

VT Chittenden VTChittenden 0.75 0.77 0.76 0.75 0.70 0.74 0.74 0.74

VT Other VTOther 0.75 0.77 0.76 0.75 0.70 0.74 0.74 0.74

WA Other WAOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

WI Other WIOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

WI Eau Claire WIEau Claire 0.87 0.92 0.88 0.93 0.69 0.83 0.83 0.83

WI Dane WIDane 0.81 0.85 0.87 0.92 0.69 0.75 0.75 0.75

WI Milwaukee WIMilwaukee 0.77 0.83 0.84 0.89 0.69 0.69 0.69 0.69

WV Other WVOther 0.69 0.69 0.69 0.69 0.69 0.69 0.69 0.69

17

CredibilityEnrollment needed for full credibility 2078

Credibility formula Sqrt(N/2078)

N=Sum(enrollment/completion factor)

E=Experience Rate

M=Manual rate

Pooling Charges

Pooling Point Unlimited

$25,000 22.7%

$50,000 13.2%

$100,000 7.0%

$250,000 2.7%

$500,000 1.0%

$5,000,000 0.0%

Rating Structure

Class Factor

Student-Only 1.00

Weights for Experience Rating

Months of

runout Year-3 Year-2 Year-1

1 20% 40% 40%

2 20% 40% 40%

3 20% 40% 40%

4 20% 40% 40%

5 20% 40% 40%

Plan Maximum

18

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTDeductible Factors DEDUCTIBLE FACTORS

Deductible Annual Cost Value Over Ded Value of Ded

0 $1,408.51

25 $1,408.49 $1,394.66 $13.85 0.98%

50 $1,407.90 $1,381.35 $27.16 1.93%

75 $1,406.90 $1,368.52 $39.99 2.84%

100 $1,405.13 $1,356.27 $52.24 3.71%

150 $1,402.58 $1,336.04 $72.48 5.15%

200 $1,399.02 $1,318.83 $89.69 6.37%

250 $1,395.88 $1,302.78 $105.74 7.51%

300 $1,391.63 $1,287.87 $120.65 8.57%

350 $1,385.17 $1,271.57 $136.94 9.72%

400 $1,378.67 $1,256.20 $152.32 10.81%

500 $1,366.85 $1,228.29 $180.22 12.80%

600 $1,355.80 $1,202.62 $205.90 14.62%

700 $1,344.67 $1,178.80 $229.72 16.31%

750 $1,338.71 $1,167.34 $241.17 17.12%

800 $1,333.21 $1,156.26 $252.25 17.91%

900 $1,323.28 $1,135.29 $273.22 19.40%

1000 $1,312.26 $1,115.54 $292.98 20.80%

1500 $1,269.51 $1,036.47 $372.04 26.41%

2000 $1,227.10 $971.69 $436.82 31.01%

2500 $1,191.59 $915.99 $492.53 34.97%

3000 $1,154.69 $867.66 $540.86 38.40%

5000 $1,046.84 $740.52 $668.00 47.43%

10000 $890.29 $571.09 $837.43 59.45%

15000 $776.35 $462.92 $945.60 67.13%

20000 $676.81 $388.72 $1,019.79 72.40%

25000 $588.99 $336.85 $1,071.67 76.08%

30000 $529.87 $297.31 $1,111.21 78.89%

35000 $477.79 $266.56 $1,141.96 81.08%

40000 $441.77 $241.13 $1,167.38 82.88%

45000 $407.15 $220.06 $1,188.46 84.38%

50000 $374.32 $202.65 $1,205.86 85.61%

55000 $350.02 $187.74 $1,220.78 86.67%

60000 $324.78 $175.11 $1,233.40 87.57%

65000 $297.27 $164.76 $1,243.75 88.30%

70000 $286.76 $155.32 $1,253.19 88.97%

75000 $284.87 $146.06 $1,262.46 89.63%

80000 $272.74 $137.56 $1,270.96 90.23%

85000 $257.66 $129.98 $1,278.53 90.77%

90000 $241.64 $123.35 $1,285.17 91.24%

95000 $234.37 $117.15 $1,291.36 91.68%

100000 $221.58 $111.61 $1,296.91 92.08%

105000 $213.51 $106.48 $1,302.03 92.44%

110000 $199.38 $102.01 $1,306.50 92.76%

115000 $196.42 $97.71 $1,310.80 93.06%

120000 $180.95 $94.05 $1,314.47 93.32%

125000 $171.27 $90.80 $1,317.71 93.55%

130000 $167.91 $87.71 $1,320.81 93.77%

135000 $167.91 $84.62 $1,323.89 93.99%

140000 $164.28 $81.66 $1,326.85 94.20%

145000 $156.75 $78.96 $1,329.55 94.39%

150000 $156.75 $76.28 $1,332.23 94.58%

200000 $123.84 $59.47 $1,349.05 95.78%

250000 $118.39 $44.62 $1,363.89 96.83%

300000 $98.00 $33.63 $1,374.89 97.61%

400000 $56.87 $24.68 $1,383.83 98.25%

500000 $56.87 $16.63 $1,391.88 98.82%

600000 $56.87 $8.59 $1,399.93 99.39%

700000 $24.32 $5.54 $1,402.97 99.61%

800000 $24.32 $2.86 $1,405.65 99.80%

900000 $24.32 $0.18 $1,408.33 99.99%

1000000 $0.00 $0.00 $1,408.51 100.00%

1250000 $0.00 $0.00 $1,408.51 100.00%

1500000 $0.00 $0.00 $1,408.51 100.00%

1750000 $0.00 $0.00 $1,408.51 100.00%

2000000 $0.00 $0.00 $1,408.51 100.00%

5000000 $0.00 $0.00 $1,408.51 100.00%

19

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONT

Deductible Factors - Presciption Drugs

Deductible Annual Cost Value Over Ded Value of Ded

0 $241.48

25 $241.23 $235.63 $5.85 2.42%

50 $239.90 $229.85 $11.63 4.82%

75 $238.60 $224.83 $16.65 6.90%

100 $237.18 $221.39 $20.09 8.32%

150 $234.25 $213.50 $27.98 11.59%

200 $231.06 $206.44 $35.04 14.51%

250 $227.80 $200.03 $41.45 17.17%

300 $224.65 $194.43 $47.05 19.48%

350 $221.39 $189.06 $52.42 21.71%

400 $218.36 $187.03 $54.45 22.55%

500 $212.36 $177.82 $63.66 26.36%

600 $207.49 $171.46 $70.02 28.99%

700 $201.83 $162.40 $79.08 32.75%

750 $199.17 $159.11 $82.37 34.11%

800 $196.95 $157.98 $83.50 34.58%

900 $193.06 $152.94 $88.54 36.66%

1000 $189.22 $158.53 $82.95 34.35%

1500 $173.47 $140.14 $101.34 41.96%

2000 $159.61 $125.92 $115.56 47.86%

2500 $148.14 $114.28 $127.20 52.68%

3000 $139.44 $117.19 $124.29 51.47%

5000 $117.74 $100.25 $141.23 58.48%

10000 $92.87 $71.88 $169.60 70.23%

15000 $76.99 $55.58 $185.90 76.98%

20000 $66.01 $44.18 $197.30 81.70%

25000 $58.84 $37.15 $204.33 84.62%

30000 $52.94 $31.11 $210.37 87.12%

35000 $48.55 $26.03 $215.45 89.22%

40000 $45.50 $22.00 $219.49 90.89%

45000 $43.19 $18.00 $223.48 92.54%

50000 $41.89 $15.31 $226.17 93.66%

55000 $40.45 $15.83 $225.65 93.45%

60000 $35.72 $15.58 $225.91 93.55%

65000 $28.86 $10.67 $230.81 95.58%

70000 $25.14 $9.47 $232.01 96.08%

75000 $21.15 $6.46 $235.02 97.33%

80000 $19.01 $7.82 $233.66 96.76%

85000 $14.46 $2.57 $238.91 98.94%

90000 $14.46 $6.90 $234.58 97.14%

95000 $9.35 $1.37 $240.11 99.43%

100000 $9.35 $3.75 $237.73 98.45%

105000 $6.51 $0.64 $240.85 99.74%

110000 $6.51 $3.43 $238.05 98.58%

115000 $3.40 $0.18 $241.30 99.93%

120000 $3.40 $3.40 $238.09 98.59%

125000 $0.00 $0.00 $241.48 100.00%

130000 $0.00 $0.00 $241.48 100.00%

135000 $0.00 $0.00 $241.48 100.00%

140000 $0.00 $0.00 $241.48 100.00%

145000 $0.00 $0.00 $241.48 100.00%

150000 $0.00 $0.00 $241.48 100.00%

200000 $0.00 $0.00 $241.48 100.00%

250000 $0.00 $0.00 $241.48 100.00%

300000 $0.00 $0.00 $241.48 100.00%

400000 $0.00 $0.00 $241.48 100.00%

500000 $0.00 $0.00 $241.48 100.00%

600000 $0.00 $0.00 $241.48 100.00%

700000 $0.00 $0.00 $241.48 100.00%

800000 $0.00 $0.00 $241.48 100.00%

900000 $0.00 $0.00 $241.48 100.00%

1000000 $0.00 $0.00 $241.48 100.00%

1250000 $0.00 $0.00 $241.48 100.00%

1500000 $0.00 $0.00 $241.48 100.00%

1750000 $0.00 $0.00 $241.48 100.00%

2000000 $0.00 $0.00 $241.48 100.00%

5000000 $0.00 $0.00 $241.48 100.00%

20

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AK Anchorage Rating Area 1

AK Dillingham Rating Area 1

AK Valdez-Cordova Rating Area 1

AK Bethel Rating Area 2

AK Bristol Bay Rating Area 2

AK Denali Rating Area 2

AK Fairbanks North Star Rating Area 2

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AK Nome Rating Area 2

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AK Wade Hampton Rating Area 2

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AK Haines Rating Area 3

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AR Cleburne Rating Area 1

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CA Los Angeles Rating Area 15

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GA Putnam Rating Area 12

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GA Wilcox Rating Area 12

GA Chattooga Rating Area 13

GA Floyd Rating Area 13

GA Gilmer Rating Area 13

GA Gordon Rating Area 13

GA Pickens Rating Area 13

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GA Appling Rating Area 14

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GA Long Rating Area 14

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GA Brooks Rating Area 15

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GA Decatur Rating Area 15

GA Early Rating Area 15

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GA Seminole Rating Area 15

GA Thomas Rating Area 15

GA Tift Rating Area 15

GA Turner Rating Area 15

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GA Wilkinson Rating Area 16

GA Walker Rating Area 7

HI Honolulu Rating Area 1

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KS Leavenworth Rating Area 1

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WI Iowa Rating Area 7

WI LaFayette Rating Area 7

WI Barron Rating Area 8

WI Rusk Rating Area 8

WI Price Rating Area 8

WI Taylor Rating Area 8

WI Clark Rating Area 8

WI Racine Rating Area 9

WI Kenosha Rating Area 9

WI Lincoln Rating Area 10

WI Marathon Rating Area 10

WI Wood Rating Area 10

WI Portage Rating Area 10

WI Waupaca Rating Area 11

WI Outagamie Rating Area 11

WI Waushara Rating Area 11

WI Winnebago Rating Area 11

WI Calumet Rating Area 11

WI Fond du Lac Rating Area 11

WI Sheboygan Rating Area 11

WI Dodge Rating Area 11

WI Washington Rating Area 12

WI Ozaukee Rating Area 12

WI Waukesha Rating Area 12

WI Iron Rating Area 13

WI Vilas Rating Area 13

WI Oneida Rating Area 13

WI Forest Rating Area 13

WI Florence Rating Area 13

WI Langlade Rating Area 13

WI Green Rating Area 14

WI Rock Rating Area 14

WI Walworth Rating Area 14

WI Jefferson Rating Area 14

WI Columbia Rating Area 14

WI Juneau Rating Area 15

WI Adams Rating Area 15

WI Marquette Rating Area 15

WI Green Lake Rating Area 15

WI Richland Rating Area 15

WI Sauk Rating Area 15

WI Marinette Rating Area 16

WI Oconto Rating Area 16

WI Menominee Rating Area 16

WI Shawano Rating Area 16

WI Brown Rating Area 16

WI Manitowoc Rating Area 16

WI Kewaunee Rating Area 16

WI Door Rating Area 16

WV Braxton Rating Area 1

WV Calhoun Rating Area 1

WV Clay Rating Area 1

WV Fayette Rating Area 1

WV Greenbrier Rating Area 1

WV Nicholas Rating Area 1

WV Roane Rating Area 1

WV Kanawha Rating Area 2

WV Boone Rating Area 3

WV Lincoln Rating Area 3

WV Logan Rating Area 3

WV Mc Dowell Rating Area 3

WV Mingo Rating Area 3

WV Wyoming Rating Area 3

WV Mercer Rating Area 4

WV Monroe Rating Area 4

WV Raleigh Rating Area 4

WV Summers Rating Area 4

WV Cabell Rating Area 5

WV Mason Rating Area 5

WV Putnam Rating Area 5

WV Wayne Rating Area 5

WV Berkeley Rating Area 6

WV Jefferson Rating Area 6

WV Grant Rating Area 7

WV Hampshire Rating Area 7

WV Hardy Rating Area 7

WV Mineral Rating Area 7

WV Morgan Rating Area 7

WV Pendleton Rating Area 7

WV Doddridge Rating Area 8

WV Gilmer Rating Area 8

WV Lewis Rating Area 8

WV Marion Rating Area 8

WV Monongalia Rating Area 8

WV Wetzel Rating Area 8

WV Barbour Rating Area 9

WV Harrison Rating Area 9

WV Pocahontas Rating Area 9

WV Preston Rating Area 9

WV Randolph Rating Area 9

WV Taylor Rating Area 9

WV Tucker Rating Area 9

WV Upshur Rating Area 9

WV Webster Rating Area 9

WV Jackson Rating Area 10

WV Pleasants Rating Area 10

WV Ritchie Rating Area 10

WV Tyler Rating Area 10

WV Wirt Rating Area 10

WV Wood Rating Area 10

WV Brooke Rating Area 11

WV Hancock Rating Area 11

WV Marshall Rating Area 11

WV Ohio Rating Area 11

WY Natrona Rating Area 1

WY Laramie Rating Area 2

WY Albany Rating Area 3

WY Big Horn Rating Area 3

WY Campbell Rating Area 3

WY Carbon Rating Area 3

WY Converse Rating Area 3

WY Crook Rating Area 3

WY Fremont Rating Area 3

WY Goshen Rating Area 3

WY Hot Springs Rating Area 3

WY Johnson Rating Area 3

WY Lincoln Rating Area 3

WY Niobrara Rating Area 3

WY Park Rating Area 3

WY Platte Rating Area 3

WY Sheridan Rating Area 3

WY Sublette Rating Area 3

WY Sweetwater Rating Area 3

WY Teton Rating Area 3

WY Uinta Rating Area 3

WY Washakie Rating Area 3

WY Weston Rating Area 3

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTRATING AREA FACTORS

AK Rating Area 1 AKRating Area 1 0.898121

AK Rating Area 2 AKRating Area 2 0.872466

AK Rating Area 3 AKRating Area 3 0.952063

AL Rating Area 1 ALRating Area 1 0.927637

AL Rating Area 10 ALRating Area 10 0.921947

AL Rating Area 11 ALRating Area 11 0.885876

AL Rating Area 12 ALRating Area 12 0.965086

AL Rating Area 13 ALRating Area 13 0.893829

AL Rating Area 2 ALRating Area 2 0.765642

AL Rating Area 3 ALRating Area 3 0.925655

AL Rating Area 4 ALRating Area 4 0.931158

AL Rating Area 5 ALRating Area 5 0.89393

AL Rating Area 6 ALRating Area 6 0.886705

AL Rating Area 7 ALRating Area 7 0.880849

AL Rating Area 8 ALRating Area 8 1.021116

AL Rating Area 9 ALRating Area 9 0.928825

AR Rating Area 1 ARRating Area 1 0.854076

AR Rating Area 2 ARRating Area 2 0.910032

AR Rating Area 3 ARRating Area 3 0.794295

AR Rating Area 4 ARRating Area 4 0.84667

AR Rating Area 5 ARRating Area 5 0.934859

AR Rating Area 6 ARRating Area 6 0.909252

AR Rating Area 7 ARRating Area 7 0.850272

AZ Rating Area 1 AZRating Area 1 0.939707

AZ Rating Area 2 AZRating Area 2 0.813733

AZ Rating Area 3 AZRating Area 3 0.983085

AZ Rating Area 4 AZRating Area 4 0.953074

AZ Rating Area 5 AZRating Area 5 0.952267

AZ Rating Area 6 AZRating Area 6 0.819267

AZ Rating Area 7 AZRating Area 7 0.788941

CA Rating Area 1 CARating Area 1 0.9411

CA Rating Area 10 CARating Area 10 1.052095

CA Rating Area 11 CARating Area 11 1.044703

CA Rating Area 12 CARating Area 12 0.987108

CA Rating Area 13 CARating Area 13 1.067042

CA Rating Area 14 CARating Area 14 1.126868

CA Rating Area 16 CARating Area 16 1.362086CA Rating Area 17 CARating Area 17 1.108946

CA Rating Area 18 CARating Area 18 1.162726

CA Rating Area 19 CARating Area 19 1.039405

CA Rating Area 2 CARating Area 2 1.010245

CA Rating Area 3 CARating Area 3 0.993973

CA Rating Area 4 CARating Area 4 1.108198

CA Rating Area 5 CARating Area 5 1.105296

CA Rating Area 6 CARating Area 6 1.160506

CA Rating Area 7 CARating Area 7 1.084862

CA Rating Area 8 CARating Area 8 0.98667

CA Rating Area 9 CARating Area 9 0.974527

CO Rating Area 1 CORating Area 1 0.827095

CO Rating Area 2 CORating Area 2 0.813998

CO Rating Area 3 CORating Area 3 0.936217

CO Rating Area 4 CORating Area 4 0.802706

CO Rating Area 5 CORating Area 5 0.707169

CO Rating Area 6 CORating Area 6 0.870572

CO Rating Area 7 CORating Area 7 0.871481

CO Rating Area 8 CORating Area 8 0.855849

CO Rating Area 9 CORating Area 9 0.744383

CT Rating Area 1 CTRating Area 1 1.206729

CT Rating Area 2 CTRating Area 2 1.12421

CT Rating Area 3 CTRating Area 3 1.06417

CT Rating Area 4 CTRating Area 4 1.094223

CT Rating Area 5 CTRating Area 5 1.278595

CT Rating Area 6 CTRating Area 6 1.12652

CT Rating Area 7 CTRating Area 7 1.036627

46

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTRATING AREA FACTORS

CT Rating Area 8 CTRating Area 8 1.116389

DC Rating Area 1 DCRating Area 1 1.193768

DE Rating Area 1 DERating Area 1 1.042242

FL Rating Area 1 FLRating Area 1 1.051074

FL Rating Area 10 FLRating Area 10 1.066244

FL Rating Area 11 FLRating Area 11 0.953257

FL Rating Area 12 FLRating Area 12 1.100277

FL Rating Area 13 FLRating Area 13 1.101291

FL Rating Area 14 FLRating Area 14 1.132563

FL Rating Area 15 FLRating Area 15 1.225544

FL Rating Area 16 FLRating Area 16 0.997693

FL Rating Area 17 FLRating Area 17 0.966635

FL Rating Area 18 FLRating Area 18 0.925757

FL Rating Area 19 FLRating Area 19 0.912763

FL Rating Area 2 FLRating Area 2 1.168882

FL Rating Area 20 FLRating Area 20 1.025157

FL Rating Area 21 FLRating Area 21 1.140542

FL Rating Area 22 FLRating Area 22 1.004551

FL Rating Area 23 FLRating Area 23 0.978318

FL Rating Area 24 FLRating Area 24 1.035998

FL Rating Area 25 FLRating Area 25 1.148777

FL Rating Area 26 FLRating Area 26 1.063673

FL Rating Area 27 FLRating Area 27 1.169419

FL Rating Area 28 FLRating Area 28 1.191484

FL Rating Area 29 FLRating Area 29 1.018802

FL Rating Area 3 FLRating Area 3 1.06705

FL Rating Area 30 FLRating Area 30 1.007826

FL Rating Area 31 FLRating Area 31 0.984614

FL Rating Area 32 FLRating Area 32 1.053909

FL Rating Area 33 FLRating Area 33 1.026363

FL Rating Area 34 FLRating Area 34 1.019657

FL Rating Area 35 FLRating Area 35 1.012295

FL Rating Area 36 FLRating Area 36 0.965153

FL Rating Area 37 FLRating Area 37 1.003936

FL Rating Area 38 FLRating Area 38 0.8877

FL Rating Area 39 FLRating Area 39 0.94044

FL Rating Area 4 FLRating Area 4 1.132058

FL Rating Area 40 FLRating Area 40 1.044433

FL Rating Area 41 FLRating Area 41 1.005703

FL Rating Area 42 FLRating Area 42 1.045702

FL Rating Area 43 FLRating Area 43 1.590119

FL Rating Area 44 FLRating Area 44 0.962845

FL Rating Area 45 FLRating Area 45 0.971779

FL Rating Area 46 FLRating Area 46 0.931551

FL Rating Area 47 FLRating Area 47 1.220646

FL Rating Area 48 FLRating Area 48 1.16955

FL Rating Area 49 FLRating Area 49 1.069931

FL Rating Area 5 FLRating Area 5 1.037883

FL Rating Area 50 FLRating Area 50 1.262188

FL Rating Area 51 FLRating Area 51 1.111109

FL Rating Area 52 FLRating Area 52 1.185028

FL Rating Area 53 FLRating Area 53 1.071292

FL Rating Area 54 FLRating Area 54 1.057957

FL Rating Area 55 FLRating Area 55 0.954324

FL Rating Area 56 FLRating Area 56 0.975304

FL Rating Area 57 FLRating Area 57 1.146889

FL Rating Area 58 FLRating Area 58 1.001924

FL Rating Area 59 FLRating Area 59 1.118817

FL Rating Area 6 FLRating Area 6 1.333405

FL Rating Area 60 FLRating Area 60 0.928726

FL Rating Area 61 FLRating Area 61 0.981997

FL Rating Area 62 FLRating Area 62 0.845278

FL Rating Area 63 FLRating Area 63 1.120585

47

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTRATING AREA FACTORS

FL Rating Area 64 FLRating Area 64 1.010051

FL Rating Area 65 FLRating Area 65 0.925941

FL Rating Area 66 FLRating Area 66 0.905327

FL Rating Area 67 FLRating Area 67 0.949933

FL Rating Area 7 FLRating Area 7 1.020233

FL Rating Area 8 FLRating Area 8 1.033177

FL Rating Area 9 FLRating Area 9 0.942065

GA Rating Area 1 GARating Area 1 0.928109

GA Rating Area 10 GARating Area 10 0.884115

GA Rating Area 11 GARating Area 11 0.995261

GA Rating Area 12 GARating Area 12 1.017309

GA Rating Area 13 GARating Area 13 0.941809

GA Rating Area 14 GARating Area 14 0.947019

GA Rating Area 15 GARating Area 15 0.966812

GA Rating Area 16 GARating Area 16 0.932202

GA Rating Area 2 GARating Area 2 0.891573

GA Rating Area 3 GARating Area 3 0.963403

GA Rating Area 4 GARating Area 4 0.952832

GA Rating Area 5 GARating Area 5 0.923463

GA Rating Area 6 GARating Area 6 0.979225

GA Rating Area 7 GARating Area 7 0.943277

GA Rating Area 8 GARating Area 8 0.947128

GA Rating Area 9 GARating Area 9 0.84912

HI Rating Area 1 HIRating Area 1 0.758087

IA Rating Area 1 IARating Area 1 0.809784

IA Rating Area 2 IARating Area 2 0.771744

IA Rating Area 3 IARating Area 3 0.851686

IA Rating Area 4 IARating Area 4 0.932851

IA Rating Area 5 IARating Area 5 0.846521

IA Rating Area 6 IARating Area 6 0.867518

IA Rating Area 7 IARating Area 7 0.898212

ID Rating Area 1 IDRating Area 1 0.745985

ID Rating Area 2 IDRating Area 2 0.791396

ID Rating Area 3 IDRating Area 3 0.794972

ID Rating Area 4 IDRating Area 4 0.848227

ID Rating Area 5 IDRating Area 5 0.857117

ID Rating Area 6 IDRating Area 6 0.895374

IL Rating Area 1 ILRating Area 1 1.141469

IL Rating Area 10 ILRating Area 10 0.919223

IL Rating Area 11 ILRating Area 11 0.936718

IL Rating Area 12 ILRating Area 12 0.972977

IL Rating Area 13 ILRating Area 13 0.951262

IL Rating Area 2 ILRating Area 2 0.986557

IL Rating Area 3 ILRating Area 3 0.993033

IL Rating Area 4 ILRating Area 4 1.063674

IL Rating Area 5 ILRating Area 5 0.912996

IL Rating Area 6 ILRating Area 6 0.902575

IL Rating Area 7 ILRating Area 7 0.877769

IL Rating Area 8 ILRating Area 8 0.82365

IL Rating Area 9 ILRating Area 9 0.946425

IN Rating Area 1 INRating Area 1 1.146516

IN Rating Area 10 INRating Area 10 1.031872

IN Rating Area 11 INRating Area 11 0.978862

IN Rating Area 12 INRating Area 12 0.889107

IN Rating Area 13 INRating Area 13 0.844748

IN Rating Area 14 INRating Area 14 0.89112

IN Rating Area 15 INRating Area 15 0.911922

IN Rating Area 16 INRating Area 16 0.98812

IN Rating Area 17 INRating Area 17 0.983433

IN Rating Area 2 INRating Area 2 0.895472

IN Rating Area 3 INRating Area 3 0.851497

IN Rating Area 4 INRating Area 4 0.935643

IN Rating Area 5 INRating Area 5 0.953456

48

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTRATING AREA FACTORS

IN Rating Area 6 INRating Area 6 0.965515

IN Rating Area 7 INRating Area 7 0.967588

IN Rating Area 8 INRating Area 8 0.98196

IN Rating Area 9 INRating Area 9 1.031604

KS Rating Area 1 KSRating Area 1 0.956423

KS Rating Area 2 KSRating Area 2 0.892276

KS Rating Area 3 KSRating Area 3 0.886071

KS Rating Area 4 KSRating Area 4 1.101647

KS Rating Area 5 KSRating Area 5 0.932479

KS Rating Area 6 KSRating Area 6 0.896216

KS Rating Area 7 KSRating Area 7 0.951732

KY Rating Area 1 KYRating Area 1 0.871631

KY Rating Area 2 KYRating Area 2 0.907687

KY Rating Area 3 KYRating Area 3 0.93064

KY Rating Area 4 KYRating Area 4 0.935421

KY Rating Area 5 KYRating Area 5 0.92315

KY Rating Area 6 KYRating Area 6 1.004032

KY Rating Area 7 KYRating Area 7 0.926391

KY Rating Area 8 KYRating Area 8 0.916491

LA Rating Area 1 LARating Area 1 1.11401

LA Rating Area 2 LARating Area 2 0.93929

LA Rating Area 3 LARating Area 3 1.03574

LA Rating Area 4 LARating Area 4 0.994332

LA Rating Area 5 LARating Area 5 1.122032

LA Rating Area 6 LARating Area 6 1.081944

LA Rating Area 7 LARating Area 7 1.176404

LA Rating Area 8 LARating Area 8 1.137309

MA Rating Area 1 MARating Area 1 1.021645

MA Rating Area 2 MARating Area 2 1.140212

MA Rating Area 3 MARating Area 3 0.989692

MA Rating Area 4 MARating Area 4 1.115183

MA Rating Area 5 MARating Area 5 1.241388

MA Rating Area 6 MARating Area 6 1.149784

MA Rating Area 7 MARating Area 7 1.136381

MD Rating Area 1 MDRating Area 1 1.273553

MD Rating Area 2 MDRating Area 2 1.130501

MD Rating Area 3 MDRating Area 3 1.094078

MD Rating Area 4 MDRating Area 4 1.096504

ME Rating Area 1 MERating Area 1 0.876901

ME Rating Area 2 MERating Area 2 0.833077

ME Rating Area 3 MERating Area 3 0.885166

ME Rating Area 4 MERating Area 4 0.90778

MI Rating Area 1 MIRating Area 1 1.257353

MI Rating Area 10 MIRating Area 10 0.9497

MI Rating Area 11 MIRating Area 11 0.876702

MI Rating Area 12 MIRating Area 12 0.917595

MI Rating Area 13 MIRating Area 13 0.893726

MI Rating Area 14 MIRating Area 14 0.866716

MI Rating Area 15 MIRating Area 15 0.900502

MI Rating Area 16 MIRating Area 16 0.81181

MI Rating Area 2 MIRating Area 2 1.161347

MI Rating Area 3 MIRating Area 3 0.963667

MI Rating Area 4 MIRating Area 4 0.974715

MI Rating Area 5 MIRating Area 5 1.217268

MI Rating Area 6 MIRating Area 6 1.006058

MI Rating Area 7 MIRating Area 7 1.010428

MI Rating Area 8 MIRating Area 8 1.031891

MI Rating Area 9 MIRating Area 9 0.87126

MN Rating Area 1 MNRating Area 1 0.892491

MN Rating Area 2 MNRating Area 2 0.866372

MN Rating Area 3 MNRating Area 3 0.848469

MN Rating Area 4 MNRating Area 4 0.967246

MN Rating Area 5 MNRating Area 5 0.948608

49

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTRATING AREA FACTORS

MN Rating Area 6 MNRating Area 6 0.898903

MN Rating Area 7 MNRating Area 7 0.872089

MN Rating Area 8 MNRating Area 8 0.940493

MN Rating Area 9 MNRating Area 9 0.978324

MO Rating Area 1 MORating Area 1 1.004813

MO Rating Area 10 MORating Area 100.884873

MO Rating Area 2 MORating Area 2 0.949369

MO Rating Area 3 MORating Area 3 0.984347

MO Rating Area 4 MORating Area 4 0.902434

MO Rating Area 5 MORating Area 5 0.828342

MO Rating Area 6 MORating Area 6 1.031853

MO Rating Area 7 MORating Area 7 0.892817

MO Rating Area 8 MORating Area 8 0.811323

MO Rating Area 9 MORating Area 9 0.851892

MS Rating Area 1 MSRating Area 1 0.998272

MS Rating Area 2 MSRating Area 2 0.902512

MS Rating Area 3 MSRating Area 3 0.991411

MS Rating Area 4 MSRating Area 4 1.032055

MS Rating Area 5 MSRating Area 5 0.971903

MS Rating Area 6 MSRating Area 6 1.045156

MT Rating Area 1 MTRating Area 1 0.809993

MT Rating Area 2 MTRating Area 2 0.761265

MT Rating Area 3 MTRating Area 3 0.73182

MT Rating Area 4 MTRating Area 4 0.791967

NC Rating Area 1 NCRating Area 1 0.788921

NC Rating Area 10 NCRating Area 10 0.96391

NC Rating Area 11 NCRating Area 11 0.964859

NC Rating Area 12 NCRating Area 12 0.973755

NC Rating Area 13 NCRating Area 13 0.892222

NC Rating Area 14 NCRating Area 14 0.997019

NC Rating Area 15 NCRating Area 15 0.921005

NC Rating Area 16 NCRating Area 16 0.89175

NC Rating Area 2 NCRating Area 2 0.89678

NC Rating Area 3 NCRating Area 3 0.897686

NC Rating Area 4 NCRating Area 4 0.949149

NC Rating Area 5 NCRating Area 5 0.956655

NC Rating Area 6 NCRating Area 6 0.97885

NC Rating Area 7 NCRating Area 7 0.915425

NC Rating Area 8 NCRating Area 8 0.918572

NC Rating Area 9 NCRating Area 9 1.013666

ND Rating Area 1 NDRating Area 1 0.814051

ND Rating Area 2 NDRating Area 2 0.848926

ND Rating Area 3 NDRating Area 3 0.941999

ND Rating Area 4 NDRating Area 4 0.846858

NE Rating Area 1 NERating Area 1 0.911142

NE Rating Area 2 NERating Area 2 0.91102

NE Rating Area 3 NERating Area 3 0.964365

NE Rating Area 4 NERating Area 4 0.96876

NH Rating Area 1 NHRating Area 1 0.896982

NJ Rating Area 1 NJRating Area 1 1.191337

NM Rating Area 1 NMRating Area 1 0.751626

NM Rating Area 2 NMRating Area 2 0.935467

NM Rating Area 3 NMRating Area 3 0.845566

NM Rating Area 4 NMRating Area 4 0.644964

NM Rating Area 5 NMRating Area 5 0.828579

NV Rating Area 1 NVRating Area 1 1.101156

NV Rating Area 2 NVRating Area 2 0.846901

NV Rating Area 3 NVRating Area 3 0.878456

NV Rating Area 4 NVRating Area 4 0.970623

NY Rating Area 1 NYRating Area 1 0.855715

NY Rating Area 2 NYRating Area 2 0.869708

NY Rating Area 3 NYRating Area 3 1.067352

NY Rating Area 4 NYRating Area 4 1.355953

50

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTRATING AREA FACTORS

NY Rating Area 5 NYRating Area 5 0.881014

NY Rating Area 6 NYRating Area 6 0.8692

NY Rating Area 7 NYRating Area 7 0.87144

NY Rating Area 8 NYRating Area 8 1.271569

OH Rating Area 1 OHRating Area 1 0.956

OH Rating Area 10 OHRating Area 10 0.956

OH Rating Area 11 OHRating Area 11 0.956

OH Rating Area 12 OHRating Area 12 0.956

OH Rating Area 13 OHRating Area 13 0.956

OH Rating Area 14 OHRating Area 14 0.956

OH Rating Area 15 OHRating Area 15 0.956

OH Rating Area 16 OHRating Area 16 0.956

OH Rating Area 17 OHRating Area 17 0.956

OH Rating Area 2 OHRating Area 2 0.956

OH Rating Area 3 OHRating Area 3 0.956

OH Rating Area 4 OHRating Area 4 0.956

OH Rating Area 5 OHRating Area 5 0.956

OH Rating Area 6 OHRating Area 6 0.956

OH Rating Area 7 OHRating Area 7 0.956

OH Rating Area 8 OHRating Area 8 0.956

OH Rating Area 9 OHRating Area 9 0.956

OK Rating Area 1 OKRating Area 1 1.000136

OK Rating Area 2 OKRating Area 2 0.909634

OK Rating Area 3 OKRating Area 3 1.012517

OK Rating Area 4 OKRating Area 4 0.935532

OK Rating Area 5 OKRating Area 5 0.982648

OR Rating Area 1 ORRating Area 1 0.831517

OR Rating Area 2 ORRating Area 2 0.766206

OR Rating Area 3 ORRating Area 3 0.836949

OR Rating Area 4 ORRating Area 4 0.783683

OR Rating Area 5 ORRating Area 5 0.844947

OR Rating Area 6 ORRating Area 6 0.85206

OR Rating Area 7 ORRating Area 7 0.764866

PA Rating Area 1 PARating Area 1 0.911972

PA Rating Area 2 PARating Area 2 0.962458

PA Rating Area 3 PARating Area 3 0.94759

PA Rating Area 4 PARating Area 4 1.013624

PA Rating Area 5 PARating Area 5 0.997062

PA Rating Area 6 PARating Area 6 1.009127

PA Rating Area 7 PARating Area 7 0.964784

PA Rating Area 8 PARating Area 8 1.164271

PA Rating Area 9 PARating Area 9 0.97054

RI Rating Area 1 RIRating Area 1 1.032953

SC Rating Area 1 SCRating Area 1 0.902467

SC Rating Area 10 SCRating Area 10 0.92423

SC Rating Area 11 SCRating Area 11 0.865901

SC Rating Area 12 SCRating Area 12 0.93534

SC Rating Area 13 SCRating Area 13 0.859344

SC Rating Area 14 SCRating Area 14 0.929881

SC Rating Area 15 SCRating Area 15 0.972072

SC Rating Area 16 SCRating Area 16 0.976736

SC Rating Area 17 SCRating Area 17 1.025578

SC Rating Area 18 SCRating Area 18 0.915201

SC Rating Area 19 SCRating Area 19 0.829854

SC Rating Area 2 SCRating Area 2 0.851883

SC Rating Area 20 SCRating Area 20 0.937539

SC Rating Area 21 SCRating Area 21 0.980532

SC Rating Area 22 SCRating Area 22 0.929534

SC Rating Area 23 SCRating Area 23 0.884152

SC Rating Area 24 SCRating Area 24 0.978948

SC Rating Area 25 SCRating Area 25 0.968238

SC Rating Area 26 SCRating Area 26 0.863542

SC Rating Area 27 SCRating Area 27 0.96397

51

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTRATING AREA FACTORS

SC Rating Area 28 SCRating Area 28 0.891501

SC Rating Area 29 SCRating Area 29 0.952133

SC Rating Area 3 SCRating Area 3 1.071729

SC Rating Area 30 SCRating Area 30 0.930744

SC Rating Area 31 SCRating Area 31 1.019346

SC Rating Area 32 SCRating Area 32 0.861776

SC Rating Area 33 SCRating Area 33 0.860774

SC Rating Area 34 SCRating Area 34 0.914398

SC Rating Area 35 SCRating Area 35 0.961589

SC Rating Area 36 SCRating Area 36 0.87837

SC Rating Area 37 SCRating Area 37 0.845876

SC Rating Area 38 SCRating Area 38 0.972459

SC Rating Area 39 SCRating Area 39 0.896551

SC Rating Area 4 SCRating Area 4 0.940421

SC Rating Area 40 SCRating Area 40 0.901788

SC Rating Area 41 SCRating Area 41 1.049624

SC Rating Area 42 SCRating Area 42 0.876084

SC Rating Area 43 SCRating Area 43 0.972897

SC Rating Area 44 SCRating Area 44 0.961026

SC Rating Area 45 SCRating Area 45 0.955457

SC Rating Area 46 SCRating Area 46 0.851145

SC Rating Area 5 SCRating Area 5 1.00766

SC Rating Area 6 SCRating Area 6 0.888821

SC Rating Area 7 SCRating Area 7 0.824708

SC Rating Area 8 SCRating Area 8 0.914672

SC Rating Area 9 SCRating Area 9 1.006879

SD Rating Area 1 SDRating Area 1 0.843817

SD Rating Area 2 SDRating Area 2 0.849606

SD Rating Area 3 SDRating Area 3 0.874311

SD Rating Area 4 SDRating Area 4 0.849572

TN Rating Area 1 TNRating Area 1 0.813444

TN Rating Area 2 TNRating Area 2 0.847147

TN Rating Area 3 TNRating Area 3 0.932862

TN Rating Area 4 TNRating Area 4 0.922714

TN Rating Area 5 TNRating Area 5 0.959992

TN Rating Area 6 TNRating Area 6 1.024071

TN Rating Area 7 TNRating Area 7 0.902631

TN Rating Area 8 TNRating Area 8 0.954144

TX Rating Area 1 TXRating Area 1 1.020935

TX Rating Area 10 TXRating Area 10 1.236075

TX Rating Area 11 TXRating Area 11 1.034133

TX Rating Area 12 TXRating Area 12 1.203442

TX Rating Area 13 TXRating Area 13 1.11832

TX Rating Area 14 TXRating Area 14 1.099889

TX Rating Area 15 TXRating Area 15 1.118745

TX Rating Area 16 TXRating Area 16 0.938183

TX Rating Area 17 TXRating Area 17 1.032615

TX Rating Area 18 TXRating Area 18 0.966709

TX Rating Area 19 TXRating Area 19 0.980761

TX Rating Area 2 TXRating Area 2 0.981302

TX Rating Area 20 TXRating Area 20 1.211475

TX Rating Area 21 TXRating Area 21 0.98988

TX Rating Area 22 TXRating Area 22 1.105851

TX Rating Area 23 TXRating Area 23 1.139945

TX Rating Area 24 TXRating Area 24 0.934566

TX Rating Area 25 TXRating Area 25 1.168688

TX Rating Area 26 TXRating Area 26 1.058855

TX Rating Area 3 TXRating Area 3 1.026468

TX Rating Area 4 TXRating Area 4 1.183031

TX Rating Area 5 TXRating Area 5 1.168161

TX Rating Area 6 TXRating Area 6 1.050497

TX Rating Area 7 TXRating Area 7 1.089885

TX Rating Area 8 TXRating Area 8 1.155405

52

NATIONAL GUARDIAN LIFE INSURANCE CO

RATE MANUAL

POLICY FORM NBH-280(2016) VT

VERMONTRATING AREA FACTORS

TX Rating Area 9 TXRating Area 9 0.943252

UT Rating Area 1 UTRating Area 1 0.863723

UT Rating Area 2 UTRating Area 2 0.856629

UT Rating Area 3 UTRating Area 3 0.88792

UT Rating Area 4 UTRating Area 4 0.879731

UT Rating Area 5 UTRating Area 5 0.83743

UT Rating Area 6 UTRating Area 6 0.817125

VA Rating Area 1 VARating Area 1 0.864208

VA Rating Area 10 VARating Area 10 0.857662

VA Rating Area 11 VARating Area 11 0.837232

VA Rating Area 12 VARating Area 12 0.85989

VA Rating Area 2 VARating Area 2 0.858126

VA Rating Area 3 VARating Area 3 0.933139

VA Rating Area 4 VARating Area 4 0.869941

VA Rating Area 5 VARating Area 5 0.829802

VA Rating Area 6 VARating Area 6 0.8559

VA Rating Area 7 VARating Area 7 0.926653

VA Rating Area 8 VARating Area 8 0.828342

VA Rating Area 9 VARating Area 9 0.925107

VT Rating Area 1 VTRating Area 1 0.859134

WA Rating Area 1 WARating Area 1 0.898928

WA Rating Area 2 WARating Area 2 0.827098

WA Rating Area 3 WARating Area 3 0.850129

WA Rating Area 4 WARating Area 4 0.895232

WA Rating Area 5 WARating Area 5 0.860769

WI Rating Area 1 WIRating Area 1 1.086686

WI Rating Area 10 WIRating Area 10 0.814716

WI Rating Area 11 WIRating Area 11 0.787618

WI Rating Area 12 WIRating Area 12 0.862736

WI Rating Area 13 WIRating Area 13 0.8207

WI Rating Area 14 WIRating Area 14 0.847594

WI Rating Area 15 WIRating Area 15 0.80274

WI Rating Area 16 WIRating Area 16 0.799076

WI Rating Area 2 WIRating Area 2 0.800246

WI Rating Area 3 WIRating Area 3 0.882412

WI Rating Area 4 WIRating Area 4 0.89094

WI Rating Area 5 WIRating Area 5 0.861687

WI Rating Area 6 WIRating Area 6 0.792459

WI Rating Area 7 WIRating Area 7 0.820732

WI Rating Area 8 WIRating Area 8 0.884228

WI Rating Area 9 WIRating Area 9 0.954079

WV Rating Area 1 WVRating Area 1 0.846511

WV Rating Area 10 WVRating Area 100.896949

WV Rating Area 11 WVRating Area 110.998037

WV Rating Area 2 WVRating Area 2 0.909549

WV Rating Area 3 WVRating Area 3 0.898939

WV Rating Area 4 WVRating Area 4 0.880727

WV Rating Area 5 WVRating Area 5 0.876095

WV Rating Area 6 WVRating Area 6 0.828134

WV Rating Area 7 WVRating Area 7 0.880454

WV Rating Area 8 WVRating Area 8 0.931209

WV Rating Area 9 WVRating Area 9 0.874103

WY Rating Area 1 WYRating Area 1 0.937025

WY Rating Area 2 WYRating Area 2 0.930449

WY Rating Area 3 WYRating Area 3 0.827431

53

Supporting Document Schedules Satisfied - Item: Transmittal Letter (A&H)Comments:Attachment(s): Cover letter - Rate Manual Filing.pdfItem Status:Status Date:

Satisfied - Item: Actuarial Memorandum and Explanatory Information (A&H)Comments:Attachment(s): NBH-280 (2016) PA PPO REV 2018 Actuarial memo 2018.pdfItem Status:Status Date:

SERFF Tracking #: NGLI-131294611 State Tracking #: NGLI-131294611 Company Tracking #: 2018-19 STUDENT HEALTH FILING -RATE

State: Pennsylvania Filing Company: National Guardian Life Insurance Company

TOI/Sub-TOI: H22 Student Health Insurance/H22.000 Student Health Insurance

Product Name: Student Health Insurance

Project Name/Number: 2018-19 Student Health Filing - Rate/2018-19 Student Health Rate Filing

PDF Pipeline for SERFF Tracking Number NGLI-131294611 Generated 01/11/2018 01:42 PM

January 2, 2018 Pennsylvania Insurance Department 1326 Strawberry Square Harrisburg, PA 17120 RE: Rate for Policy form NBH-280 (2015) PPO PA rev 2016, et al VIA SERFF To the Department: The attached student health insurance rates are being submitted for review and approval by the Pennsylvania Insurance Department. The rates are for the 2018-19 school year. 1. Company Name/NAIC – National Guardian Life Insurance Company, 66583. 2. Forms – please note that we have not filed a new form for 2018-19. We reviewed the guidance provided by the

Department and believe that our forms are in compliance. We are filing an informational filing: Form number Form Description SERFF Tracking Approval Date

NBH-280 (2015) PPO PA rev 2018 Policy - network NGLI-130507324 February 9, 2017 NBH Amend 2017 PA Amendment to update policy NGLI-130961800 April 12, 2017 NBH SCH PPO PA Schedule – network policy NGLI-130961800 April 12, 2017 NBH SCH PA Schedule – non network policy NGLI-130961800 April 12, 2017 NBH-280 (2014) PA Rev 2018 Policy – non network N/A - exempt

3. Estimated effective dates of coverage – August 1, 2017-July 31, 2018 4. Current number of covered lives and policyholder (as of November 1, 2017) – 1,385. 5. Rating areas – please see page 9 of the Actuarial Memorandum. If you have questions, please feel free to contact me. Julie Guess jaguess@nglic.com Product Compliance Analyst National Guardian Life Insurance Company Two East Gilman Street Madison, WI 53703 608-443-5035

ACTUARIAL MEMORANDUM NATIONAL GUARDIAN LIFE INSURANCE COMPANY

PENNSYLVANIA NBH-280 (2015) PPO PA Rev 2018 et al

1/2/2018 Page 1 of 11

1. General Information

a. Company Information:

• Company Legal Name: National Guardian Life Insurance Co • NAIC Number: 66583

b. Company Contact Information:

• Primary Contact Name: Alan Shulman, ASA MAAA • Primary Contact Telephone Number: 315-797-5200 x276 • Primary Contact Address: 70 Genesee St Utica NY 13502 • Primary Contact Email Address: ashulman@commercialtravelers.com

c. Scope and Purpose of the Filing:

This filing is to submit our rate manual to be used in experience rating ACA compliant Student Health plans for the 2018 school year. Separate rate filings will be submitted for specific schools, if required, when quotes are issued.

d. Market: Student Health e. Policy Forms:

NBH-280 (2015) PPO PA Rev 2016 , NBH-280 (2014) PA Rev 2018

Brief description of the Benefits: Benefits for PPACA compliant student plan including all essential health benefits f. Marketing Method: Marketed through independent agents/MGUs g. Identification of Block as Open or Closed:

Open

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h. Terminated Products/Plans: N/A 2. Proposed Rates

a. History of Rate Adjustments:

2016 2017

NORTHHAMPTON COMMUNITY COLLEGE $ 2,238.00 $ 2,516.00 12.4% LEHIGH UNIVERSITY $ 1,809.00 $ 1,866.00 3.2% b. Effective Date and Implementation of Proposed Rate Adjustment: 8/1/18 c. Proposed Percentage Rate Adjustment: Will vary by school d. Brief Description of How Rates were Determined: See attached rate manual pages for our rating formula with full definitions. The rate manual’s Starting Claim Cost was developed from experience of several schools throughout the US with high maximum plans similar to a package of PPACA-compliant benefits, or PPACA compliant for 2014 school year and greater. This development is shown in Section 3(c).

Plans will be experience rated according to the formula on page 4 of the rate manual.

e. Average Annual Premium per Member:

$1,941

f. Number of Policy Holders and Covered Lives in the States:

1385

3. Base Period Premium and Claims

a. Dates of Service for the Base Period Used to Develop Rates:

ACTUARIAL MEMORANDUM NATIONAL GUARDIAN LIFE INSURANCE COMPANY

PENNSYLVANIA NBH-280 (2015) PPO PA Rev 2018 et al

1/2/2018 Page 3 of 11

8/15/13 to 8/15/16 or

2013 to 2015 school year

b. Date Through Which Claims Were Paid:

9/30/16

c. Estimated of Allowed Claims During the Base Period Used to Develop Rates:

See 6(a)

d. Treatment of Experience for Grandfathered Policies:

N/A

e. Method Used for Determining Allowed Claims:

Experience for PPACA compliant plans for 2013 through 2015 school years.

f. Incurred But Not Paid Claims:

See Chart above

g. Premium in Base Period (Before MLR Rebates):

4. Adjustments to Allowed Claims During the Base Period

Benefit change factors were based on internal experience and account for the increase in plan maximums from 2013 ($500K) to unlimited.

New Essential Health Benefits were considered de minimus for the purpose of this filing as Preventive benefits were already included in data and pediatric dental/vision only applies to a fraction of our potential population due to age and low child dependent enrollment.

a. Private Reinsurance:

None factored into experience

b. Pooling:

Pooling table in rate manual, developed from internal experience.

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5. Projection Factors

a. Changes in Covered Services:

Benefit change factors based on internal data.

c. Trend Factors (cost/utilization):

Trend factors were based on the 2017 Milliman Medical Index adjusted for school year dates vs. calendar year. We are using a trend of 6% for future periods as this is closer to the recent historic average. Cost trends have typically exceeded utilization trends in the past so the following breakdown supports this.

Cost Utilization

• Inpatient 2.9% 3% • Outpatient 2.9% 3% • Professional 2.9% 3% • Other Medical 2.9% 3% • Prescription Drugs 2.9% 3%

d. Projected Changes in the Demographics of the Population Insured:

None

e. Projected Changes in the Morbidity of the Population Insured:

None

e. Other Projected Changes:

6. Credibility Manual Rate Development

a. Methodology Used to Develop the Credibility Manual Rate:

The pricing model used is based on a starting point of Allowed Charges, which is then adjusted to reflect cost-sharing with the insured. The data used for the starting claim cost was derived from several years of experience for PPACA compliant plans. These schools were located in several states throughout the US. To arrive at the starting claim cost before cost-sharing, we used the trended Allowed Charges (after network discounts) from these plans as shown below:

School Year

2014 2015 2016 2017

A Allowed Charges $ 33,946,422 $ 43,645,043 $ 69,918,768

ACTUARIAL MEMORANDUM NATIONAL GUARDIAN LIFE INSURANCE COMPANY

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B Area Rating Factor 1.0140 1.0313 1.0012 C Adjusted Allowed Charges $ 33,476,742 $ 42,320,666 $ 69,834,966 D Completion factor 1.0000 1.0090 1.0760

E Benefit Change factor 1.000 1.000 1.000 F Incurred Allowed Charges $ 33,476,742 $ 42,701,552 $ 75,142,424

G Exposure 25,743 28,880 52,423 45,752

H Incurred Allowed per person $ 1,300 $ 1,479 $ 1,433

Annual Trend Assumption

I

5.3% 4.5% 5.3% 6.0%

J

1.228 1.166 1.116

K Trended Incurred Allowed Charges $ 41,117,063 $ 49,807,436 $ 83,872,470 L Exposure 25,743 28,880 52,423 M Trended Incurred Allowed per person $ 1,597 $ 1,725 $ 1,600 N Percent Applied 0.1 0.4 0.5

O 2017 Projected Allowed $ 1,650 P Allowed to Charges Ratio 0.7133 0.6779 0.6987

Q Average Discount 0.692

Definititions

A Allowed Charges including network discounts B Average Geographic Rating Factor based on CMS data (see below)

C A/B D Completion Factors based on internal data

E Factor to increase plan maximum to unlimited F C*D*E

G Average insured exposure H F/G I Trends based on Milliman Index J Cumulative Trend Factor K F*J L Exposure M K/L N Weight applied to each year O 2017 Projected Allowed = Sum(N*M) P Average discount from Charges Q Average discount weighted - sum(P*N)

The Trended Incurred Allowed per Person of $1,650 is the Starting Claim Cost in the Rate Manual. Deductible and cost sharing factors, network discounts

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b. Source and Appropriateness of Experience Data Used:

Internal experience was considered credible for manual rating

c. Adjustments Made to the Data:

Benefit adjustments made according to Milliman study mentioned above

d. Inclusion of Capitation Payments:

N/A

7. Credibility

Please note that student health is not subject to single risk pool requirements

a. Credibility Methodology: The credibility formula is based on the traditional credibility formula (Z=sqrt(n/k), where k is the value of student lives needed for full credibility, based on confidence intervals), and n is the number of students in the experience period. We multiply this percentage times the remaining credibility (1-Z).

b. Credibility Level(s):

Enrollment needed for full credibility

2078

Credibility formula

Sqrt(N/2078)

N=Sum(enrollment/completion factor)

E=Experience Rate

M=Manual rate

8. Credibility Adjusted Projected Claims PMPM

N/A

9. Projected Index Rate

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N/A – Student insurance rated based on a nationwide pool

10. Market Adjusted Index Rate

N/A

a. Risk Transfer Payments/Charges:

N/A

b. Transitional Reinsurance:

No longer applicable

c. Connector User Fees:

N/A

11. Paid to Allowed Ratio

Student not subject to single risk pool requirement

12. Non-Benefit Expenses Including Risk and Profit Margin

a. Projected Non-Benefit Expenses:

ADMINISTRATIVE EXPENSES

Ranges Commission:

0-3%

Claim Payor/TPA:

5-12% QIE

0-2%

Carrier:

3-6% Profit Margin:

3-5%

Ranges are determined by relationship with claim payor/TPA and what is charged for their services The total administrative expense/profit will not exceed the amount constrained by the Federal Minimum Loss Ratio according to the following formula. QIE stands for quality improvement expenses.

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Taxes and Assessments

PPACA PCORI Fee (Per Life, Same All Classes) $2.32(.1%) State Premium Tax & Assessments 2.00%

PPACA Annual Health Insurer (HI) Fee 2.75%

Federal Minimum Loss Ratio calculation

In general,

(Claims+QIE Expenses)/(Premium-Taxes and Fees)

Claims Cost – $1,341.04

QIE pp expenses - $0 PPACA pp fees - $2.32 Total retention including profit and percentage fees (incl QIE as %) - .20 QIE % Fees – 2% Taxes – 4.75% (Claims Cost + QIE % Fees (Premium) + QIE PP expenses)/(Premium-Taxes*Premium-PPACA pp fees) (1341.04+.0*1763+0)/(1763-.0475*1763-2.32)=80% Where premium =, (Claims Cost +QIE pp expenses + PPACA pp fees)/ (1-Total Retention+QIE % Fees)*(1-Taxes-(QIE % Fees)/(1-Total retention+QIE % Fees)) (1341.04+0+2.32)/ (1-.20+.0)*(1-.0475-(.0/(1-.20+.0))) = $1,763 (rounded to nearest dollar)

b. Varying Non-Benefit Expenses by Plan:

None

13. Allowable Rating Factors

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a. Age Factors:

None

b. Geographic Factors: The table of geographic rating factors in the rate manual is based on CMS published data for Medicare beneficiaries in Pennsylvania and is used as a proxy for cost differentials by the allowed rating regions. The rating areas are based on the CMS list of counties by rating area. While no data is available considering the difference in mix of services between a student and Medicare population, the differentials are considered reliable as an indicator of cost differentials amongst various areas. In theory, the mix of services may have an impact on the cost differentials but we consider it most likely that both professional and facility charges will be similarly high or low depending on the cost of living in each region. The national average from the Medicare data is $9,500.63.

c. Tobacco Factors: None

d. Family Composition:

Factor

Student-Only

1.00

14. Development of Rate Tables N/A

15. Company Financial Position NGL is an A- rated carrier by AM Best. Loss Ratios

a. Loss Ratio Requirements:

Plans will be rated at or above the defined permissible loss ratio of 80% (excluding the impact of State premium taxes and Federal/PPACA fees and assessments, as allowed by law).

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b. Projected Federal MLR:

80%

16. Reliance N/A

17. Projected Enrollment 1385

18. Actuarial Certifications

I, Alan Shulman, ASA MAAA, am a member of the American Academy of Actuaries (Academy) and I meet the Academy qualification standards for rendering this opinion. I certify that, to the best of my knowledge and judgment: • The entire rate filing is in compliance with the applicable laws of the state of Pennsylvania and with the rules of the Office of the Commissioner of Insurance, • The development of the projected index rate and all rating factors is in compliance with all applicable federal statutes and regulations, • Each school will be rated using “school-specific community rating” as outlined in CMS-9972-F • The index rate and allowable modifiers as described in 45 CFR § 156.80 (d)(1) and 45 CFR § 156.80(d)(2) are used in the development of plan-specific premium rates, • All plans will meet the minimum value requirements detailed in 45 CFR § 147.145 (b)(2), • The methodology used to calculate the AV Metal Value for each plan complies with federal regulations, • The geographic rating factors reflect only differences in the costs of delivery and do not include differences for population morbidity by geographic area, • The entire rate filing, including development of the projected index rate and all rating factors, complies with all applicable Actuarial Standards of Practice, • The projected index rate and rating factors are reasonable in relation to the benefits provided and the population anticipated to be covered, and • The premium schedule, including the projected index rate and rating factors, is not excessive, deficient, nor unfairly discriminatory.

_____________________

Alan Shulman, ASA MAAA

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