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

Press TAB and directional arrow keys to read through the document. 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. If screen reader fails to announce a cell after performing a dropdown selection, please press F2 and then ESC to force the screen reader to resume.

Unified Rate Review v6.0 [assistive technology users, please reference cell A1 for instructions]

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:

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

HIOS Issuer ID:

State:

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

Effective Date of Rate Change(s):

12/30/1899

Market:

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

Year 1 Trend

Year 2 Trend

Benefit Category

Experience Period Index Rate PMPM

Cost

Utilization

Cost

Utilization

Trended EHB Allowed Claims PMPM

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

12/30/1899

$0.00

Manual EHB Allowed Claims PMPM

Applied Credibility %

Projected Period Totals

Projected Index Rate for

12/30/1899

$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

Press TAB and directional arrow keys to read through the document. 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 P6. If screen reader fails to announce a cell after performing a dropdown selection, please press F2 and then ESC to force the screen reader to resume.		Product-Plan Data Collection [assistive technology users, please reference cell A1 for instructions]											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:													To validate, select the Validate button or Ctrl + Shift + I.
		HIOS Issuer ID:		State:											To finalize, select the Finalize button or Ctrl + Shift + F.
		Effective Date of Rate Change(s):	12/30/1899	Market:											To remove a product, navigate to the corresponding Product Name/Product ID field and select the Remove Product button or Ctrl + Shift + Q.
															To remove a plan, navigate to the corresponding Plan Name/Plan ID field and select the Remove Plan button or Ctrl + Shift + A.
		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 [assistive technology users, please reference cell A2 for instructions]		Specify the total number of Rating Areas in your State by selecting the Create Rating Areas button or Ctrl + Shift + R.
Press TAB and directional arrow keys to read through the document. 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. If screen reader fails to announce a cell after performing a dropdown selection, please press F2 and then ESC to force the screen reader to resume.		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