Health Insurance Issuer Submission of the Preliminary Justification

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Overview

Wksh 1 - Market Experience
Wksh 2 - Plan Product Info
Wksh 3 - Rating Areas

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Sheet 1: Wksh 1 - Market Experience

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells K1 through K4.

Unified Rate Review v5.0

To add a product to Worksheet 2 - Plan Product Info, select the Add Product button or Ctrl + Shift + P.

To add a plan to Worksheet 2 - Plan Product Info, select the Add Plan button or Ctrl + Shift + L.

Company Legal Name:

State:

To validate, select the Validate button or Ctrl + Shift + I.

HIOS Issuer ID:

Market:

To finalize, select the Finalize button or Ctrl + Shift + F.

Effective Date of Rate Change(s):

Market Level Calculations (Same for all Plans)

Section I: Experience Period Data

Experience Period:

to

12/30/1900

Total

PMPM

Allowed Claims

#DIV/0!

Reinsurance

#DIV/0!

Incurred Claims in Experience Period

#DIV/0!

Risk Adjustment

#DIV/0!

Experience Period Premium

#DIV/0!

Experience Period Member Months

0

Section II: Projections

Benefit Category

Experience Period Index Rate PMPM

Year 1 Trend

Year 2 Trend

Trended EHB Allowed Claims PMPM

Cost

Utilization

Cost

Utilization

Inpatient Hospital

$0.00

Outpatient Hospital

$0.00

Professional

$0.00

Other Medical

$0.00

Capitation

$0.00

Prescription Drug

$0.00

Total

$0.00

$0.00

Morbidity Adjustment

Demographic Shift

Plan Design Changes

Other

Adjusted Trended EHB Allowed Claims PMPM for

$0.00

Manual EHB Allowed Claims PMPM

Applied Credibility %

Projected Period Totals

Projected Index Rate for

$0.00

$0.00

Reinsurance

$0.00

Risk Adjustment Payment/Charge

$0.00

Exchange User Fees

$0.00

Market Adjusted Index Rate

$0.00

$0.00

Projected Member Months

0

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

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Sheet 2: Wksh 2 - Plan Product Info

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells P1 through P4.		Product-Plan Data Collection												To add a product to Worksheet 2 - Plan Product Info, select the Add Product button or Ctrl + Shift + P.
														To add a plan to Worksheet 2 - Plan Product Info, select the Add Plan button or Ctrl + Shift + L.
		Company Legal Name:											State:		To validate, select the Validate button or Ctrl + Shift + I.
		HIOS Issuer ID:											Market:		To finalize, select the Finalize button or Ctrl + Shift + F.
		Effective Date of Rate Change(s):
		Product/Plan Level Calculations
	Field #	Section I: General Product and Plan Information
	1.1	Product Name
	1.2	Product ID
	1.3	Plan Name
	1.4	Plan ID (Standard Component ID)
	1.5	Metal
	1.6	AV Metal Value
	1.7	Plan Category
	1.8	Plan Type
	1.9	Exchange Plan?
	1.10	Effective Date of Proposed Rates
	1.11	Cumulative Rate Change % (over 12 mos prior)
	1.12	Product Rate Increase %
	1.13	Submission Level Rate Increase %
Worksheet 1 Totals		Section II: Experience Period and Current Plan Level Information
	2.1	Plan ID (Standard Component ID)	Total
$0	2.2	Allowed Claims	$0
$0	2.3	Reinsurance	$0
	2.4	Member Cost Sharing	$0
	2.5	Cost Sharing Reduction	$0
$0	2.6	Incurred Claims	$0
$0	2.7	Risk Adjustment Transfer Amount	$0
$0	2.8	Premium	$0
0	2.9	Experience Period Member Months	0
	2.10	Current Enrollment	0
	2.11	Current Premium PMPM	#NAME?
	2.12	Loss Ratio	#DIV/0!
		Per Member Per Month
	2.13	Allowed Claims	#DIV/0!
	2.14	Reinsurance	#DIV/0!
	2.15	Member Cost Sharing	#DIV/0!
	2.16	Cost Sharing Reduction	#DIV/0!
	2.17	Incurred Claims	#DIV/0!
	2.18	Risk Adjustment Transfer Amount	#DIV/0!
	2.19	Premium	#DIV/0!
		Section III: Plan Adjustment Factors
	3.1	Plan ID (Standard Component ID)
	3.2	Market Adjusted Index Rate
	3.3	AV and Cost Sharing Design of Plan
	3.4	Provider Network Adjustment
	3.5	Benefits in Addition to EHB
		Administrative Costs
	3.6	Administrative Expense
	3.7	Taxes and Fees
	3.8	Profit & Risk Load
	3.9	Catastrophic Adjustment
	3.10	Plan Adjusted Index Rate
	3.11	Age Calibration Factor
	3.12	Geographic Calibration Factor
	3.13	Tobacco Calibration Factor
	3.14	Calibrated Plan Adjusted Index Rate
		Section IV: Projected Plan Level Information
	4.1	Plan ID (Standard Component ID)	Total
	4.2	Allowed Claims	$0
	4.3	Reinsurance	$0
	4.4	Member Cost Sharing	$0
	4.5	Cost Sharing Reduction	$0
	4.6	Incurred Claims	$0
	4.7	Risk Adjustment Transfer Amount	$0
	4.8	Premium	$0
	4.9	Projected Member Months	0
	4.10	Loss Ratio	#DIV/0!
		Per Member Per Month
	4.11	Allowed Claims	#DIV/0!
	4.12	Reinsurance	#DIV/0!
	4.13	Member Cost Sharing	#DIV/0!
	4.14	Cost Sharing Reduction	#DIV/0!
	4.15	Incurred Claims	#DIV/0!
	4.16	Risk Adjustment Transfer Amount	#DIV/0!
	4.17	Premium	#DIV/0!

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Sheet 3: Wksh 3 - Rating Areas

Rating Area Data Collection		Specify the total number of Rating Areas in your State by selecting the Create Rating Areas button or Ctrl + Shift + R.
If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells C1 through C4.		Select only the Rating Areas you are offering plans within and add a factor for each area.
		To validate, select the Validate button or Ctrl + Shift + I.
		To finalize, select the Finalize button or Ctrl + Shift + F.
Rating Area	Rating Factor
OMB control number: 0938-1141
Expiration date: XX/XX/XXXX
PRA Disclosure Statement: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 0938-1141. The time required to complete this information collection is estimated to average [1.5 hour] 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 Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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 0938-1141. The time required to complete this information collection
is estimated to average [0.08 hour] 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 Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.