Download:
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pdfInstructions
1. A complete submission will include the following tables completed according to the
instructions described below: the State Information table; and either the Silver Plan and Bronze
Plan Data Tables A (for states that use age as a rating factor for premiums) or Tables B (for
states that do not use age as a rating factor for premiums).
2. For the purpose of this report, the enrollee is defined as an individual policyholder (except
for categories specified in Tables B for states that use family tier ratios for rate setting).
3. Include in the name of the return Excel file the following: a) state, b) date sent, c) BHP State
Report for Exchange Premiums
completeness, accuracy and compliance with the instructions provided herein, have the state
official: a) sign an attestation indicating that the data has been reviewed and is complete,
accurate and in compliance with the instructions; b) direct the attestation to the attention of the
Director of the Center for Medicaid and CHIP Services; and c) copy the signed attestation into
a PDF file.
[email protected]. Include in the subject line, 'BHP State Report for
Exchange Premiums'.
6. For technical assistance, notify Jessica Schubel at [email protected].
1. State Information - Questionnaire Questions
1. State:
Select the appropriate two-letter state abbreviation from the drop-down menu in cell B10.
2. State official attesting to the data's completeness, accuracy, and compliance with CMS
specification.
3. State staff responsible for answering technical questions concerning the data submission.
Provide the appropriate information for the state employee to contact for questions about the
information provided in this report.
4. Date:
Enter the date that the information in this report was certified and submitted to CMS.
2. Silver Plan Data Table A
Use this table if the state uses age as a rating factor for the Health Insurance Exchange
premiums.
Enter the information for each county or county equivalent entity in the state. Enter the
information for each county or county-equivalent entity by row.
For counties or county-equivalent entities where, in different portions of the county, either (a)
different silver level qualified health plans charge the second lowest cost premium in different
portions of the county or county-equivalent entity, or (b) different bronze level qualified health
plans charge the lowest premium in different portions of the county or county-equivalent entity,
provide the information for the portion of the county or county-equivalent entity that contains
the greatest number of residents in the county or county-equivalent entity and for the specified
1. County:
Enter the name of the county or county-equivalent entity.
2. County ID:
Enter each county's or county-equivalent entity's 3-digit ANSI code. For a list of ANSI codes,
see:
3. Second Lowest Cost Silver Plan Name:
Enter the name of the second lowest cost silver level qualified health plan operating in the
county or county-equivalent entity.
For the purposes of this report, the second lowest cost silver level qualified health plan is
defined as the silver level qualified health plan that charges the second lowest monthly
premium among all silver level qualified health plans that are offering coverage to any county
residents who are qualified to purchase coverage on the Health Insurance Exchange.
The plan name is defined as the Plan Marketing Name in Table 2 of CCIIO's Plan Management
Benefits & Service Area User Guide, Version 3.0; Last Modified: May 20, 2013.
4. Second Lowest Cost Silver Plan Issuer:
Enter the name of the issuer of the second lowest cost silver level qualified health plan
operating in the county or county-equivalent entity.
The Issuer Legal Name is described as “Issuer Legal Name” in Table 2 in the CCIIO document,
“Plan Management (PM), Issuer Module User Guide, Version: 9.0, Last Modified: May 20,
2013.” (The Issuer Legal Name may be different from the Issuer Marketing Name.)
5. Second Lowest Cost Silver Plan ID:
Enter the plan ID for second lowest cost silver level qualified health plan operating in the
county or county-equivalent entity.
The plan's 14-digit Plan ID is described in Table 1 in the CCIIO document, “Plan Management
(PM), Rating Module User Guide, Version: 4.0, Last Modified: May 15, 2013.” The Plan ID
consists of a 5-digit, numerical issuer ID; a two-letter state postal code; a 3-digit Product ID
number; and a 4-digit Plan Unique Identifier Number. For example, 12345FL1234567 is a Plan
ID number that includes an issuer ID (12345), a state postal code (FL), a Product ID number
6. Second Lowest Cost Silver Plan Coverage:
If a single silver level qualified health plan charges the second lowest cost premium through the
entire county or county-equivalent entity, enter or select "1".
If there is not a single silver level qualified health plan that charges the second lowest cost
premium throughout the entire county or county-equivalent entity, enter or select "2".
7. Monthly premium for 10-year-old enrollee:
Enter the monthly premium charged for a 10-year-old enrollee by the second lowest cost silver
level qualified health plan.
8. Monthly premium for 21-year-old non-tobacco user enrollee:
Enter the monthly premium charged for a 21-year-old non-tobacco user enrollee by the
second lowest cost silver level qualified health plan. If the state does not allow tobacco use as
a rating factor, enter the monthly premium charged for a 21-year-old enrollee.
9. Monthly premium for 21-year-old tobacco user enrollee:
Enter the monthly premium charged for a 21-year-old tobacco user enrollee by the second
lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating
10. Monthly premium for 35-year-old non- tobacco user enrollee:
Enter the monthly premium charged for a 35-year-old non-tobacco user enrollee by the second
lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating
factor, enter the monthly premium charged for a 35-year-old enrollee.
11. Monthly premium for 35-year-old tobacco user enrollee:
Enter the monthly premium charged for a 35-year-old tobacco user enrollee by the second
lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating
12. Monthly premium for 45-year-old non-tobacco user enrollee:
Enter the monthly premium charged for a 45-year-old non-tobacco user enrollee by the second
lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating
factor, enter the monthly premium charged for a 45-year-old enrollee.
13. Monthly premium for 45-year-old tobacco user enrollee:
Enter the monthly premium charged for a 45-year-old tobacco user enrollee by the second
lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating
14. Monthly premium for 55-year-old non-tobacco user enrollee:
Enter the monthly premium charged for a 55-year-old non-tobacco user enrollee by the second
lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating
factor, enter the monthly premium charged for a 55-year-old enrollee.
15. Monthly premium for 55-year-old tobacco user enrollee:
Enter the monthly premium charged for a 55-year-old tobacco user enrollee by the second
lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating
3. Bronze Plan Data Table A
Use this table if the state uses age as a rating factor for the Health Insurance Exchange
premiums.
Enter the information for each county or county equivalent entity in the state. Enter the
information for each county or county-equivalent entity by row.
For counties or county-equivalent entities where, in different portions of the county, either (a)
different silver level qualified health plans charge the second lowest cost premium in different
portions of the county or county-equivalent entity, or (b) different bronze level qualified health
plans charge the lowest premium in different portions of the county or county-equivalent entity,
provide the information for the portion of the county or county-equivalent entity that contains
1. County:
Enter the name of the county or county-equivalent entity.
2. County ID:
Enter each county's or county-equivalent entity's 3-digit ANSI code. For a list of ANSI codes,
see: http://www.census.gov/geo/reference/codes/cou.html.
3. Lowest Cost Bronze Plan Name:
Enter the name of the lowest cost bronze level qualified health plan operating in the county or
county-equivalent entity. For the purposes of this report, the lowest cost bronze level qualified
health plan is defined as the bronze level qualified health plan that charges the lowest monthly
premium among all bronze level qualified health plans that are offering coverage to any county
residents who are qualified to purchase coverage on the Health Insurance Exchange. The
plan name is defined as the Plan Marketing Name in Table 2 of CCIIO's Plan Management
Benefits & Service Area User Guide, Version 3.0; Last Modified: May 20, 2013.
4. Lowest Cost Bronze Plan Issuer:
Enter the name of the issuer of the lowest cost bronze level qualified health plan operating in
the county or county-equivalent entity. The Issuer Legal Name is described as “Issuer Legal
Name” in Table 2 in the CCIIO document, “Plan Management (PM), Issuer Module User Guide,
Version: 9.0, Last Modified: May 20, 2013.” (The Issuer Legal Name may be different from the
5. Lowest Cost Bronze Plan ID:
Enter the plan ID for lowest cost bronze level qualified health plan operating in the county or
county-equivalent entity.
The plan's 14-digit Plan ID is described in Table 1 in the CCIIO document, “Plan Management
(PM), Rating Module User Guide, Version: 4.0, Last Modified: May 15, 2013.” The Plan ID
consists of a 5-digit, numerical issuer ID; a two-letter state postal code; a 3-digit Product ID
number; and a 4-digit Plan Unique Identifier Number. For example, 12345FL1234567 is a Plan
ID number that includes an issuer ID (12345), a state postal code (FL), a Product ID number
6. Lowest Cost Bronze Plan Coverage:
If a single bronze level qualified health plan charges the lowest cost premium through the entire
county or county-equivalent entity, enter or select "1". If there is not a single bronze level
qualified health plan that charges the lowest cost premium throughout the entire county or
7. Monthly premium for 10-year-old enrollee:
Enter the monthly premium charged for a 10-year-old enrollee by the lowest cost bronze level
qualified health plan.
8. Monthly premium for 21-year-old non-tobacco user enrollee:
Enter the monthly premium charged for a 21-year-old non-tobacco user enrollee by the lowest
cost bronze level qualified health plan. If the state does not allow tobacco use as a rating
factor, enter the monthly premium charged for a 21-year-old enrollee.
9. Monthly premium for 21-year-old tobacco user enrollee:
Enter the monthly premium charged for a 21-year-old tobacco user enrollee by the lowest cost
bronze level qualified health plan. If the state does not allow tobacco use as a rating factor,
10. Monthly premium for 45-year-old non-tobacco user enrollee:
Please provide the monthly premium charged for a 45-year-old non-tobacco user enrollee by
the lowest cost bronze level qualified health plan. If the state does not allow tobacco use as a
rating factor, enter the monthly premium charged for a 45-year-old enrollee.
11. Monthly premium for 35-year-old non-tobacco user enrollee:
Enter the monthly premium charged for a 21-year-old non-tobacco user enrollee by the lowest
cost bronze level qualified health plan. If the state does not allow tobacco use as a rating
factor, enter the monthly premium charged for a 35-year-old enrollee.
12. Monthly premium for 35-year-old tobacco user enrollee:
Enter the monthly premium charged for a 35-year-old tobacco user enrollee by the lowest cost
bronze level qualified health plan. If the state does not allow tobacco use as a rating factor,
13. Monthly premium for 45-year-old tobacco user enrollee:
Enter the monthly premium charged for a 45-year-old tobacco user enrollee by the lowest cost
bronze level qualified health plan. If the state does not allow tobacco use as a rating factor,
14. Monthly premium for 55-year-old non-tobacco user enrollee:
Enter the monthly premium charged for a 55-year-old non-tobacco user enrollee by the lowest
cost bronze level qualified health plan. If the state does not allow tobacco use as a rating
factor, enter the monthly premium charged for a 55-year-old enrollee.
15. Monthly premium for 55-year-old tobacco user enrollee:
Enter the monthly premium charged for a 55-year-old tobacco user enrollee by the lowest cost
bronze level qualified health plan. If the state does not allow tobacco use as a rating factor,
4. Silver Plan Data Table B
Use this table if the state does not use age as a rating factor for the Health Insurance
Exchange premiums.
Enter the information for each county or county equivalent entity in the state. Enter the
information for each county or county-equivalent entity by row.
For counties or county-equivalent entities where, in different portions of the county, either (a)
different silver level qualified health plans charge the second lowest cost premium in different
portions of the county or county-equivalent entity, or (b) different bronze level qualified health
plans charge the lowest premium in different portions of the county or county-equivalent entity,
provide the information for the portion of the county or county-equivalent entity that contains
1. County:
Enter the name of the county or county-equivalent entity.
2. County ID:
Enter each county's or county-equivalent entity's 3-digit ANSI code. For a list of ANSI codes,
see: http://www.census.gov/geo/reference/codes/cou.html.
3. Second Lowest Cost Silver Plan Name:
Enter the name of the second lowest cost silver level qualified health plan operating in the
county or county-equivalent entity.
For the purposes of this report, the second lowest cost silver level qualified health plan is
defined as the silver level qualified health plan that charges the second lowest monthly
premium among all silver level qualified health plans that are offering coverage to any county
residents who are qualified to purchase coverage on the Health Insurance Exchange.
The plan name is defined as the Plan Marketing Name in Table 2 of CCIIO's Plan Management
Benefits & Service Area User Guide, Version 3.0; Last Modified: May 20, 2013.
4. Second Lowest Cost Silver Plan Issuer:
Enter the name of the issuer of the second lowest cost silver level qualified health plan
operating in the county or county-equivalent entity.
The Issuer Legal Name is described as “Issuer Legal Name” in Table 2 in the CCIIO document,
“Plan Management (PM), Issuer Module User Guide, Version: 9.0, Last Modified: May 20,
2013.” (The Issuer Legal Name may be different from the Issuer Marketing Name.)
5. Second Lowest Cost Silver Plan ID:
Enter the plan ID for second lowest cost silver level qualified health plan operating in the
county or county-equivalent entity.
The plan's 14-digit Plan ID is described in Table 1 in the CCIIO document, “Plan Management
(PM), Rating Module User Guide, Version: 4.0, Last Modified: May 15, 2013.” The Plan ID
consists of a 5-digit, numerical issuer ID; a two-letter state postal code; a 3-digit Product ID
number; and a 4-digit Plan Unique Identifier Number. For example, 12345FL1234567 is a Plan
ID number that includes an issuer ID (12345), a state postal code (FL), a Product ID number
6. Second Lowest Cost Silver Plan Coverage:
If a single silver level qualified health plan charges the second lowest cost premium through
the entire county or county-equivalent entity, enter or select "1". If there is not a single silver
level qualified health plan that charges the second lowest cost premium throughout the entire
t
t
i 1l adult
t tit
t
l t "2"
7. Monthly
premium
for
enrollee:
Enter the monthly premium charged for a 1 adult enrollee by the second lowest cost silver level
qualified health plan.
8. Monthly premium for 2 adult enrollees:
Enter the total monthly premium charged for 2 adult enrollees by the second lowest cost silver
level qualified health plan.
9. Monthly premium for 1 adult and 1 or more child enrollees:
Enter the total monthly premium charged for 1 adult and 1 or more child enrollees by the
second lowest cost silver level qualified health plan.
10. Monthly premium for 2 adult and 1 or more child enrollees:
Enter the total monthly premium charged for 2 adult and 1 or more child enrollees by the
second lowest cost silver level qualified health plan.
5. Bronze Plan Data Table B
Use this table if the state does not use age as a rating factor for the Health Insurance
Exchange premiums.
Enter the information for each county or county equivalent entity in the state. Enter the
information for each county or county-equivalent entity by row.
For counties or county-equivalent entities where, in different portions of the county, either (a)
different silver level qualified health plans charge the second lowest cost premium in different
portions of the county or county-equivalent entity, or (b) different bronze level qualified health
plans charge the lowest premium in different portions of the county or county-equivalent entity,
provide the information for the portion of the county or county-equivalent entity that contains
1. County:
Enter the name of the county or county-equivalent entity.
2. County ID:
Enter each county's or county-equivalent entity's 3-digit ANSI code. For a list of ANSI codes,
see: http://www.census.gov/geo/reference/codes/cou.html.
3. Lowest Cost Bronze Plan Name:
Enter the name of the lowest cost bronze level qualified health plan operating in the county or
county-equivalent entity.
For the purposes of this report, the lowest cost bronze level qualified health plan is defined as
the bronze level qualified health plan that charges the lowest monthly premium among all
bronze level qualified health plans that are offering coverage to any county residents who are
qualified to purchase coverage on the Health Insurance Exchange.
The plan name is defined as the Plan Marketing Name in Table 2 of CCIIO's Plan Management
Benefits & Service Area User Guide, Version 3.0; Last Modified: May 20, 2013.
4. Lowest Cost Bronze Plan Issuer:
Enter the name of the issuer of the lowest cost bronze level qualified health plan operating in
the county or county-equivalent entity.
The Issuer Legal Name is described as “Issuer Legal Name” in Table 2 in the CCIIO document,
“Plan Management (PM), Issuer Module User Guide, Version: 9.0, Last Modified: May 20,
2013.” (The Issuer Legal Name may be different from the Issuer Marketing Name.)
5. Lowest Cost Bronze Plan ID:
Enter the plan ID for lowest cost bronze level qualified health plan operating in the county or
county-equivalent entity.
The plan's 14-digit Plan ID is described in Table 1 in the CCIIO document, “Plan Management
(PM), Rating Module User Guide, Version: 4.0, Last Modified: May 15, 2013.” The Plan ID
consists of a 5-digit, numerical issuer ID; a two-letter state postal code; a 3-digit Product ID
number; and a 4-digit Plan Unique Identifier Number. For example, 12345FL1234567 is a Plan
ID number that includes an issuer ID (12345), a state postal code (FL), a Product ID number
6. Lowest Cost Bronze Plan Coverage:
If a single bronze level qualified health plan charges the lowest cost premium through the entire
county or county-equivalent entity, enter or select "1". If there is not a single bronze level
qualified health plan that charges the lowest cost premium throughout the entire county or
7. Monthly premium for 1 adult enrollee:
Enter the monthly premium charged for a 1 adult enrollee by the lowest cost bronze level
8. Monthly premium for 2 adult enrollees:
Enter the total monthly premium charged for 2 adult enrollees by the lowest cost bronze level
9. Monthly premium for 1 adult and 1 or more child enrollees:
Enter the total monthly premium charged for 1 adult and 1 or more child enrollees by the lowest
cost bronze level qualified health plan.
10. Monthly premium for 2 adult and 1 or more child enrollees:
Enter the total monthly premium charged for 2 adult and 1 or more child enrollees by the lowest
cost bronze level qualified health plan.
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons
are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-1218. This
collection is approved through July 31, 2014. The time required to complete this information
collection is estimated to average 4.0 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
State Information
1. State
Reporting State
2. State official attesting to the data's completeness, accuracy, and compliance with CMS specifications
Name
Title
Agency
Email address
Phone
Mailing address
3. State staff responsible for answering technical questions concerning the data submission
Name
Title
Agency
Email address
Phone
4. Date
Date submitted
Mailing address
Health Insurance Exchange Silver Plan Data - Table A
See "Instructions" for information on how to enter data into the table.
Notes
1. Only enter data in Table A if the state uses age as a rating factor for premiums. Do not enter data in Table A if the state does not
use age as a rating factor for premiums.
2. Only enter premiums for tobacco users if the state uses tobacco use as a rating factor for premiums.
3. All premium data should reflect monthly premiums.
State
0
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Monthly
Premium for 21year-old nontobacco user
enrollee
Monthly
Premium for 21year-old
tobacco user
enrollee
Monthly
Premium for 35year-old nontobacco user
enrollee
Monthly
Premium for
35-year-old
tobacco user
enrollee
Monthly
Premium for 45year-old nontobacco user
enrollee
Monthly
Premium for 45year-old
tobacco user
enrollee
Monthly
Premium for
55-year-old
non-tobacco
user enrollee
Monthly
Premium for
55-year-old
tobacco user
enrollee
Health Insurance Exchange Bronze Plan Data - Table A
See "Instructions" for information on how to enter data into the table.
Notes
1. Only enter data in Table A if the state uses age as a rating factor for premiums. Do not enter data in Table A if the state does not
use age as a rating factor for premiums.
2. Only enter premiums for tobacco users if the state uses tobacco use as a rating factor for premiums.
3. All premium data should reflect monthly premiums.
State
0
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 10-year-old
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old
year-old nonyear-old
year-old
year-old
year-old nonyear-old nonyear-old nontobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Premium for 21- Premium for 21- Premium for 35- Premium for 35- Premium for 45- Premium for 45- Premium for 55- Premium for 55year-old nonyear-old nonyear-old
year-old nonyear-old
year-old nonyear-old
year-old
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
tobacco user
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
enrollee
Health Insurance Exchange Silver Plan Data - Table B
See "Instructions" for information on how to enter data into the table.
Notes
1. Only enter data in Table B if the state does not use age as a rating factor for premiums. Do not enter data in Table B if the state
does use age as a rating factor.
2. All premium data should reflect monthly premiums.
State
0
Second Lowest
Second Lowest
Second Lowest
Second Lowest
Cost Silver Plan Cost Silver Plan Cost Silver Plan Cost Silver Plan Monthly Premium
County Name
County ID
Name
Issuer
ID
Coverage
for 1 Adult
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Second Lowest
Cost Silver Plan
Name
Second Lowest
Cost Silver Plan
Issuer
Second Lowest
Cost Silver Plan
ID
Second Lowest
Cost Silver Plan
Coverage
Monthly Premium
for 1 Adult
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Health Insurance Exchange Bronze Plan Data - Table B
See "Instructions" for information on how to enter data into the table.
Notes
1. Only enter data in Table B if the state does not use age as a rating factor for premiums. Do not enter data in Table B if the state
does use age as a rating factor.
2. All premium data should reflect monthly premiums.
State
0
Lowest Cost
Lowest Cost
Lowest Cost
Bronze Plan
Bronze Plan
Lowest Cost
Bronze Plan
Monthly Premium
County Name
County ID
Name
Issuer
Bronze Plan ID
Coverage
for 1 Adult
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 1 Adult
County Name
County ID
Lowest Cost
Bronze Plan
Name
Lowest Cost
Bronze Plan
Issuer
Lowest Cost
Bronze Plan ID
Lowest Cost
Bronze Plan
Coverage
Monthly Premium
for 1 Adult
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
Monthly Premium Monthly Premium
Monthly Premium for 1 Adult and 1 for 2 Adults and 1
for 2 Adults
or More Children or More Children
| File Type | application/pdf |
| Author | Dorn, Stan |
| File Modified | 2014-04-08 |
| File Created | 2014-04-08 |