CMS-10379.Rate Summary Form (7-12-11) w comment changes highlighted

Per the Instructions, health insurance issuers proposing rate increases that meet or exceed the threshold fill in only those cells that are highlighted in GREY.
The other cells are auto-populated.
A. Base Period Data
				Start Period:	5/1/2009											End Period:	4/30/2010
Service Categories							Member Months						Total Allowed						Net Claims						Cost Sharing						Cost Sharing PMPM						Net PMPM						Allowed PMPM
Inpatient							10,000						$313,250.00						$244,355.00						$68,895.00						$6.89						$24.44						$31.33
Outpatient							10,000						$311,000.00						$242,580.00						$68,420.00						$6.84						$24.26						$31.10
Professional							10,000						$774,000.00						$603,720.00						$170,280.00						$17.03						$60.37						$77.40
Prescription Drugs							10,000						$498,000.00						$368,500.00						$129,500.00						$12.95						$36.85						$49.80
Ancillary Services							10,000						$45,800.00						$35,700.00						$10,100.00						$1.01						$3.57						$4.58
Capitation							10,000						$75,000.00						$75,000.00						$-						$-						$7.50						$7.50
Total							10,000						$2,017,050.00						$1,569,855.00						$447,195.00						$44.72						$156.99						$201.71
B. Claim Projections
B1. Adjustment to the Current Rate																																	B2. Claims Projection for Future Rate
				Start Period:	1/1/2010											End Period:	12/31/2010																				Start Period:	1/1/2011											End Period:	12/31/2011
Service Categories							Overall Medical Trend						Projected Allowed PMPM						Net Claims						Cost Sharing								Service Categories							Overall Medical Trend						Projected Allowed PMPM						Net Claims						Cost Sharing
Inpatient							1.0154						$31.81						$25.13						0.21								Inpatient							1.0783						$34.30						$26.75						0.22
Outpatient							1.0462						$32.54						$25.70						0.21								Outpatient							1.1185						$36.39						$28.39						0.22
Professional							1.0284						$79.60						$62.88						0.21								Professional							1.0877						$86.58						$67.53						0.22
Prescription Drugs							1.0669						$53.13						$39.85						0.25								Prescription Drugs							1.1316						$60.12						$44.79						0.26
Ancillary Services							1.0155						$4.65						$3.67						0.21								Ancillary Services							1.0812						$5.03						$3.92						0.22
Capitation							1.0100						$7.58						$6.67						0.12								Capitation							1.0210						$7.73						$7.73						0.00
Total													$209.30						$163.90						0.22								Total													$230.15						$179.11						0.22
B3. Medical Trend Breakout
Factor							Impact
Utilization							50.0%
Unit Cost							40.0%
Other Factors							10.0%
C. Components of Current and Future Rates
											Future Rate												Prior Estimate of Current Rate												Difference
											PMPM						%						PMPM						%						PMPM						%
1. Projected Net Claims											$179.11						76.20%						$159.20						75.73%						$19.91						80.22%
2. Administrative Costs											$45.75						19.46%						$43.33						20.61%						$2.42						9.75%
3. Underwritng Gain/Loss											$10.19						4.34%						$7.70						3.66%						$2.49						10.03%
4. Total Rate											$235.05						100.00%						$210.23						100.00%						$24.82						100.00%
5. Overall Rate Increase																	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								Calendar Year						New Form						Requested					Implemented
																													2010						N						10.00%					10.00%
Claims Components																													2009						N						8.00%					8.00%
1.		Inpatient													$1.97						9.87%								2008						N						7.00%					7.00%
2.		Outpatient													$3.05						15.30%
3.		Professional													$5.51						27.68%								F. Range and Scope of Proposed Increase
4.		Prescription Drugs													$5.24						26.32%
5.		Other													$0.30						1.50%								Number of Covered Individuals
6.		Capitation													$0.14						0.70%								900
7.		Cost Share													$(1.00)						-5.00%
8.		Correction of Prior Net Claims Estimate													$4.70						23.62%
9.		Total													$19.91						100.00%
Claims Restatement for Current Rate Period (1/1/2010-12/31/2010)																																				Range of Rate Increase
8.a. Prior Net Claims Estimate for Current Rate Period																					$159.20								Minimum % Increase							5.00%
8.b. Re-Estimate of Net Claims PMPM for Current Rate Period																					$163.90								Maximum % Increase							13.60%