Rate Summary Worksheet

Rate Summary Worksheet

Per the Instructions, health insurance issuers proposing rate increases above the threshold fill in only those cells that are highlighted in GREY.
The other cells are auto-populated.

A. Base Period Data
Start Period: 05/01/2009
Service
Categories
Inpatient
Outpatient
Professional
Prescription Drugs
Other
Capitation
Total

End Period: 04/30/2010
Member
Months
10,000
10,000
10,000
10,000
10,000
10,000
10,000

$
$
$
$
$
$
$

Total
Allowed
313,250.00
311,000.00
774,000.00
498,000.00
45,800.00
75,000.00
2,017,050.00

Net
Claims
244,355.00
242,580.00
603,720.00
368,500.00
35,700.00
75,000.00
1,569,855.00

$
$
$
$
$
$
$

$
$
$
$
$
$
$

Cost Sharing
68,895.00
68,420.00
170,280.00
129,500.00
10,100.00
447,195.00

$
$
$
$
$
$
$

Cost
Sharing PMPM
6.89
6.84
17.03
12.95
1.01
44.72

Net
PMPM
$
$
$
$
$
$
$

24.44
24.26
60.37
36.85
3.57
7.50
156.99

Allowed
PMPM
31.33
31.10
77.40
49.80
4.58
7.50
201.71

$
$
$
$
$
$
$

B. Claim Projections
B1. Adjustment to the Current Rate

B2. Claims Projection for Future Rate

Start Period: 01/01/2010
Service
Categories
Inpatient
Outpatient
Professional
Prescription Drugs
Other
Capitation
Total

End Period: 12/31/2010

Overall
Medical Trend
1.0154
1.0462
1.0284
1.0669
1.0155
1.0100

Projected
Allowed PMPM
$
31.81
$
32.54
$
79.60
$
53.13
$
4.65
$
7.58
$
209.30

Start Period: 01/01/2011
Net
Claims

$
$
$
$
$
$
$

25.13
25.70
62.88
39.85
3.67
7.58
164.81

Cost Sharing
0.21
0.21
0.21
0.25
0.21
0.00
0.21

Service
Categories
Inpatient
Outpatient
Professional
Prescription Drugs
Other
Capitation
Total

End Period: 12/31/2011

Overall
Medical Trend
1.0783
1.1185
1.0877
1.1316
1.0812
1.0210

$
$
$
$
$
$
$

Projected
Allowed PMPM
34.30
36.39
86.58
60.12
5.03
7.73
230.15

Net
Claims
$
$
$
$
$
$
$

26.75
28.39
67.53
44.79
3.92
7.73
179.11

B3. Medical Trend Breakout

Factor
Utilization
Unit Cost
Other Factors

Impact
50.0%
40.0%
10.0%

C. Components of Current and Future Rates

1. Projected Net Claims
2. Administrative Costs
3. Underwritng Gain/Loss
4. Total Rate

$
$
$
$

Future Rate
PMPM
179.11
45.75
10.19
235.05

5. Overall Rate Increase

%
76.20%
19.46%
4.34%
100.00%

$
$
$
$

Prior Estimate of Current Rate
PMPM
%
159.20
75.73%
43.33
20.61%
7.70
3.66%
210.23
100.00%

$
$
$
$

Difference
PMPM
19.91
2.42
2.49
24.82

%
80.22%
9.75%
10.03%
100.00%

11.81%

D. Components of Rate Increase

E. List of Annual Average Rate Changes Requested and Implemented in the Past Three Calendar Years
Impact
on Rate

Percent

Claims Components
1. Inpatient
$
1.97
2. Outpatient
$
3.05
3. Professional
$
5.51
4. Prescription Drugs
$
5.24
5. Other
$
0.30
6. Capitation
$
0.16
7. Cost Share Change
$
(1.92)
8. Correction of Prior Net Claims Estimate
$
5.61
9. Total
$
19.91
Claims Restatement for Current Rate Period (1/1/2010-12/31/2010)
8.a. Prior Net Claims Estimate for Current Rate Period
8.b. Re-Estimate of Net Claims PMPM for Current Rate Period

9.87%
15.30%
27.68%
26.32%
1.50%
0.80%
-9.66%
28.18%
100.00%

$
$

159.20
164.81

Calendar Year
2010
2009
2008

New Form
N
N
N

Requested
Implemented
10.00%
10.00%
8.00%
8.00%
7.00%
7.00%

F. Range and Scope of Proposed Increase
Number of Covered Individuals
900

Minimum % Increase
Maximum % Increase

Range of Rate
Increase
5.00%
13.60%

Cost Sharing
0.22
0.22
0.22
0.26
0.22
0.00
0.22