Supporting Document Schedules · 2019. 7. 26. · Initial requested average rate change: 11.5%1...

Supporting Document Schedules Satisfied - Item: ACA Public Rate Filing PDFComments:

Attachment(s): Public Rate Filing QCC Small Group 072519 (pages 1 to 68).pdfPublic Rate Filing QCC Small Group 072519 (pages 69 to 145).pdf

Item Status:Status Date:

SERFF Tracking #: INAC-131927133 State Tracking #: INAC-131927133 Company Tracking #: QCC SG 1-1-2020

State: Pennsylvania Filing Company: QCC Insurance Company

TOI/Sub-TOI: H15G Group Health - Hospital/Surgical/Medical Expense/H15G.003 Small Group Only

Product Name: QCC Small Group PPO effective 1-1-2020

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number INAC-131927133 Generated 07/25/2019 04:42 PM

May 21, 2019

Ms. Tracie Gray, Director

Bureau of Accident and Health Insurance

Pennsylvania Insurance Department

1311 Strawberry Square

Harrisburg, PA 17120

SUBMITTED VIA SERFF

RE: QCC Insurance Company, Inc.

Small Group PPO Rate Filing effective 1/1/2020

INAC-131927133

Dear Ms. Gray:

Attached is the 2020 annual rate filing for PPO plans of QCC Insurance Company, Inc.

(QCC) in the Small Group marketplace in the Commonwealth of Pennsylvania. Rates for

new and renewing plans are being filed and satisfy market reform requirements of the

Affordable Care Act (ACA).

This rate filing includes rates for these plans and specifies compliance with rating

requirements of the ACA. The enclosed is for rating periods effective from January 1,

2019 through December 31, 2020.

The proposed rates represent a 11.9% increase over the previously approved 2019 rates.

Information for the Pennsylvania Bulletin:

1. Company Name and NAIC Number: QCC Insurance Company, Inc.

93688

2. Market Small Group

3. On or Off Exchange Off

4. Effective Date of Coverage January 1, 2020

5. Average Rate Change Requested 11.9%

6. Range of Rate Changes Requested 9.4% to 13.5%

7. Total Annual Revenue Generated from

the Proposed Rate Change $60,708,604

8. Products PPO

9. Rating Areas and Change from 2019 Rating Area 8

No Change from 2019

10. Metal Levels and Catastrophic Plans Platinum, Gold, Silver, Bronze

11. Current covered lives and policyholders 71,592 covered lives

as of February 1, 2019 9,525 policyholders

12. Number of plans offered in 2020 and 19 plans in 2020; 19 plans in 2019

change from 2019

13. Corresponding contract form number, Please see appendix.

SERFF, and binder numbers

14. HIOS Issuer ID # and submission tracking HIOS Issuer ID # 31609; Tracking #

Number 31609-1488627405223891969

Please contact XXXXXXXXXX at XXXXXXXXXX or XXXXXXXXXX with any

questions regarding this filing.

Sincerely,

XXXXXXXXXXXXXXXXXXXX

Director and Actuary, Commercial Pricing

cc: XXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXX

APPENDIX

SERFF ID #s:

INLG-131932874

INLG-131932846

INBC-131932910

INBC-131932865

Form Numbers

16884.WR-III Rev. 1.20

16884-BC.SG.OFF Rev. 1.20

16884-BC.SG.OFF.HSA.HRA Rev. 1.20

17014.WR Rev. 1.20

17014-BC.SG.OFF.HSA Rev. 1.20

16905.WR.KDPOS Rev. 1.20

16905-BC.SG.KDPOS.OFF Rev. 1.20

16906.WR.ADPOS Rev. 1.20

16906-BC.SG.ADPOS.OFF Rev. 1.20

PREV/SCH-II Rev. 1.20

Rate Change Summary

QCC Insurance Company, Inc. – Small Group Plans

Rate request filing ID INAC-131927133- This document is prepared by the insurance company submitting the rate filing as a consumer tool to help explain the rate filing. It is not intended to describe or include all factors or information considered in the review process. For more information, see the filing at http://www.insurance.pa.gov/Consumers/ACARelatedFilings/

Overview Initial requested average rate change: 11.5%1 Revised requested average rate change: N/A1 Range of requested rate change: 9.1% to 13.2% Effective date: January 1, 2020 People impacted: 71,592 Available in: Area 8

Key information

Jan. 2018-Dec. 2018 financial experience

Premiums $506,462,339

Claims $360,479,052

Administrative expenses $65,129,741

Taxes & fees $30,623,261

Company made (after taxes) $50,230,285

The company expects its annual medical costs to increase 6.2%.

Explanation of requested rate change

QCC Insurance Company ("QCC”) is revising premium rates for the Pennsylvania Small Group ACA compliant products, effective from January 1, 2020. About 72,000 members will be affected. Financial Experience of the Product: QCC is required by federal law to pay out a minimum of 80% percent of premium dollars for medical claims—this is referred to as the minimum Medical Loss Ratio (MLR). The rate action proposed in this filing is expected to achieve a Medical Loss Ratio of greater than 80%.

1 Note that insurers will have the opportunity to revise their rate change request in July, after they are scheduled to receive updated information about the impact of a federal program called risk adjustment. This document will be updated accordingly at that time.

How it plans to spend your premium This is how the insurance company plans to spend the premium it collects in 2020:

Claims: 76% Administrative: 14% Taxes & fees: 8% Profit: 2%

http://www.insurance.pa.gov/Consumers/ACARelatedFilings

Changes in Taxes and Fees: The Federal government suspended the Health Insurance Providers Fee for premiums due in 2019, but will be re-implementing it for premiums due in 2020. This increases 2020 premium rates. Changes in Medical Service Costs: Premium rates for health care insurance are increasing as the cost of health care service rise. Health care service costs increase as health care providers increase their fees, members use more health care services and supplies, and the types of health care services and supplies change, among other factors. We are projecting that claims will increase by 6.2% in 2020. Nearly half of the change in health care service costs is driven by changes to health care provider fees. Changes in Benefits: Some plan benefits are mandated by federal and state law. Benefit changes for some plans were also made. All changes in benefits are in compliance with the uniform modifications rules stipulated by the Federal government. Administrative Costs: In addition, the Affordable Care Act (ACA) imposes taxes and other levies.

INAC-131927133 1 PA Actuarial Memorandum QCC Small Group 1Q2020 May 21, 2019

PENNSYLVANIA ACTUARIAL MEMORANDUM

PURPOSES

This Actuarial Memorandum is provided along with the Unified Rate Review Template (URRT) and PA

Actuarial Memorandum Rate Exhibits to provide certain information to support the gross premium for

the single risk pool for small group market health care insurance underwritten by QCC Insurance Co.,

Inc. in the Commonwealth of Pennsylvania. It is provided as a component of a state rate filing. This

submission may not be appropriate for other purposes.

1. BASIC INFORMATION AND DATA

A. COMPANY INFORMATION

Company Legal Name: QCC Insurance Co., Inc. (“QCC”)

State: Pennsylvania

NAIC #: 93688

Market: Small Group

Marketplace: Off Exchange

Effective Date(s): 1/1/2020 – 3/31/2020, 4/1/2020 – 6/30/2020, 7/1/2020 – 9/30/2020,

10/1/2020 – 12/31/2020

Average Rate Change: 11.9%

Range of Rate Changes: 9.4% - 13.5%

Products: PPO

Rating Areas: Rating Area 8

Metal Levels: Platinum, Gold, Silver, Bronze

Current Members: 71,592

Current Policyholders: 9,525

Number of 2020 Plans: 19

HIOS Issuer ID (5-digit): 31609

Worksheet 1 of the accompanying URRT contains experience period data and development of the

projected Single Risk Pool Gross Premium Average Rate PMPM for the small group market for QCC.

Worksheet 2 contains experience period data and projections by product for the single risk pool for the

same entities. This memorandum pertains only to plans denoted in Worksheet 2 by Plan IDs starting

with the sequence 31609.

COMPANY CONTACT INFORMATION

Primary Contact Name: XXXXXXXXXX

Primary Contact Telephone Number: XXXXXXXXXX

Primary Contact Email Address: XXXXXXXXXX


B. RATE HISTORY AND PROPOSED VARIATIONS IN RATE CHANGES

January 1, 2015 8.50% INAC- 129626740

October 1, 2015 -0.30% INAC- 130111048

January 1, 2016 6.51% INAC- 129939280

January 1, 2017 5.00% INAC- 130539936

July 1, 2017 2.00% INAC- 130959332

January 1, 2018 9.41% INAC- 131005785

July 1, 2018 0.05% INAC- 131403779

January 1, 2019 -1.80% INAC- 131478429

April 1, 2019 -0.09% INAC- 131750255

July 1, 2019 -1.80% INAC- 131860461

The historical rate changes varied by metallic tier based on plan benefits as illustrated via the Pricing AV.

Proposed rate changes may vary by metallic tier and plan based on plan benefit changes.

C. AVERAGE RATE CHANGE

The average proposed rate change shown in Cell AC15 of Table 10 is 11.9%. The changes to the single

risk pool gross premium average rate per member per month (PMPM) from calendar year 2018 to

calendar year 2020 are incorporated into the pricing and reflected in the Unified Rate Review Template.

The change in 21-year-old Non-Tobacco Premium PMPM calculated in Table 11, Cell AN13 is 5.3%.

D. MEMBERSHIP COUNT

Table 1 illustrates the Experience Period member-months, Current Period members as of February 1,

2019, and Projected Rating Period Member-months by ages.

E. BENEFIT CHANGES

Benefit changes were made to the following plans to assure compliance with Actuarial Value

Requirements, including differences that resulted from changes to the AV Calculator. The basis for

pricing changes was our internal pricing model.

F. EXPERIENCE PERIOD CLAIMS AND PREMIUMS

Table 2 illustrates the experience period claims and premiums using calendar year data. The data is

consistent with the data reported in Section 1 of Worksheet I of the URRT.


Experience period premium, claims, and member months are obtained from the company’s internal

data warehouse. The claims data is collected for incurred dates from January through December 2018

and paid through February 2019. Earned premiums and member months are for January through

December 2018. The data are for all direct-written Small group business of QCC in the Commonwealth

of Pennsylvania, including out-of-network claims written by QCC but paid by QCC for POS plans. No

private reinsurance was applicable.

Projected Risk Adjustment PMPM

The Non-EHB benefits portion of Allowed Claims is shown separately in cell H36 of Table 2. Capitation is

uniform by age for the experience period. Net pharmacy rebates are illustrated in cell I36 of Table 2.

Projected Risk Adjustment is accounted for in Projected Incurred Claims before ACA Reinsurance and

Risk Adjustment to reflect anticipated risk adjustment transfer amounts for the projection period. The

amount reflects the projected morbidity for the single risk pool for IBCFOC in the projection period.

The estimated risk adjustment revenue for all of the plans in the risk pool is developed using the

following methodology. We recognize that the HHS payment transfer formula implies that the projected

incurred claims based solely on the experience period single risk pool claims need to be adjusted by the

ratio of the current statewide market’s risk relative to allowable rating factor (ARF) for age compared to

the single risk pool’s risk relative to ARF presented during the experience period. This adjustment,

together with the assumed future changes in population risk morbidity, results in the issuer’s pricing

being consistent with the anticipated morbidity level of the future statewide market.

The anticipated risk adjustment transfer revenue is allocated proportionally based on plan premium.

The Projected Risk Adjustment is subtracted from Projected Incurred Claims before ACA Risk Adjustment

to reflect anticipated receipt of risk adjustment transfer amounts for the projection period.

When the projected risk adjustment amounts for QCC and Independence Blue Cross (QCC) are

combined, the result is consistent with the projection made in our submission. We also considered

preliminary 2018 risk transfer results.

In the URRT v5.0, it is necessary to divide Risk Adjustment by the Paid to Allowed factor when it is used

in calculations based on Allowed Claims to produce calculations that are consistent with the Actuarial

Memo Rate Exhibit.

G. CREDIBILITY OF DATA

The experience period data is considered 100% credible.


H. TREND IDENTIFICATION

Table 3 identifies the proposed annual medical and prescription drug allowed claims cost and utilization

trends. These data match the data illustrated in Section 2 of Worksheet I of the URRT. Additional

discussion is provided in Section I, Historical Experience.

We populated the URRT with the Total Annual Trend calculated in cell C52 of Table 3. The URRT

requires that factors are rounded to four decimal places which results in some small differences.

I. HISTORICAL EXPERIENCE

Table 4 illustrates historical experience from 2015 through 2018 for the product line.

a. Annualized Cost Trend

Annual cost trend reflects changes in costs of medical treatment due to medical inflation and changes in

the distribution of services across network providers. The trend value is developed by reviewing

historical medical costs for the single risk pool and adjusting them for anticipated future provider

contracting reimbursement levels. The data is normalized for changes in age, benefit changes during the

experience period, changes to provider contracts, and prescription drug formulary, and new drugs

brought to market.

b. Annualized Utilization Trend

Annual utilization trend reflects the change in the number of units per 1,000 members for a fixed level

of illness burden and includes changes due to the mix and intensity of services provided and changes

related to shifts in product mix. It also includes effects of selection, if any, since this cannot be reflected

in the relative cost of the various products and plans offered.

J. TERMINATED PLANS

No plans are being terminated during 2020.

2. RATE DEVELOPMENT AND CHANGE

A. DEVELOPMENT OF PROJECTED INDEX RATE, MARKET-ADJUSTED INDEX RATE, & TOTAL

ALLOWED CLAIMS

Table 5 illustrates the development of the Projected Index Rate and Market-Adjusted Index Rate

beginning with the Experience Period Index Rate. Exhibit A provides additional information about the

adjustment factors.


Changes in Population Risk Morbidity

Experience period allowed claims are adjusted to account for differences in the average morbidity of the

single risk pool population underlying the experience and the anticipated population in the projection

period. This adjustment reflects changes in the small group market-wide morbidity.

Changes in Other Factors

Experience period allowed claims are adjusted to account for differences in the single risk pool

population underlying the experience and the anticipated population in the projection period pertaining

to several factors not due to changes in morbidity or the costs and utilization of medical care. This

adjustment reflects: additional benefits required to be covered as essential health benefits; recently

mandated benefits required by state law that are not reflected in the experience period data; benefits in

the experience that are removed for the projection period; anticipated changes in the average

utilization of services due to differences in average cost sharing requirements during the experience

period and average cost sharing requirements in the projection period; changes in demographic

characteristics of the single risk pool experience period population and the projection period population

(including age, gender, region, and tobacco use); changes in the provider network (adding or removing a

provider system or introducing a limited network option); and anticipated changes in pharmacy rebates.

We incorporated the quarterly trend methodology from Table 5A into the URRT Part 1 Worksheet 1

Section II so that the calculated MAIR in the URRT was consistent with the MAIR calculated in the

Actuarial Memo Rate Exhibits. The factor is also applied in the URRT Worksheet 2 Section 3, Plan

Adjustment Factors, to correctly calculate the first quarter 2020 rates.

Table 5 of the Actuarial Memorandum Rate Exhibit shows the components used in calculating change in

other. The calculations of the components are based on the changes in values shown in Table 7.

B. RETENTION ITEMS

Table 6 illustrates the retention items, expressed as percentages of premium. Consistent with

conversations with our State regulator, no Pricing load was applied for the Managed Care Assessment

levied pursuant to Article VIII-I of the Pennsylvania Code, as it will be separately reimbursed. Federal

Income Tax is calculated by applying the tax rate to the sum of the HIF plus Profit/Contingency.

Administrative Expenses 14.65%

General and Claims 8.45%

Agent/Broker Fees and Commissions 5.40%

Quality Improvement Initiatives 0.80%

Taxes and Fees 5.84%

PA Premium Tax 2.00%

Federal Income Tax 1.14%

Health Insurance Providers Fee 2.70%


Profit/Contingency 2.00%

Total Retention 22.49%

C. NORMALIZED MARKET-ADJUSTED PROJECTED ALLOWED TOTAL CLAIMS

Table 7 compares the normalization factors used in this filing to those used in the 2019 filing. The

changes in the factors reflect small differences from the projected populations in 2019 and 2020.

D. COMPONENTS OF RATE CHANGE

Table 8 illustrates the components of rate change, based on inputs form other sections of the Rate

Exhibits. The results in Row H are similar to the values in Row A of Table 8.

Data in Table 9 is consistent with the 2019 and 2020 URRT with the exceptions of Risk Adjustment and

Reinsurance which were revised to project company-specific values.

3. PLAN RATE DEVELOPMENT

Table 10 is populated with plan information consistent with entries in the 2020 URRT. Plan mappings,

where applicable, are illustrated in Column F of Table 10.

Attached to this actuarial memorandum are exhibits providing actuarial certifications for the use of

alternate methods of calculating the Actuarial Value, where applicable, as well as required support for

the calculations.

The factor “AV and Cost Sharing Design of Plan” in Worksheet 2 of the URRT is the product of the Pricing

AV, the Benefit Richness Factors from the Actuarial Memo Rate Exhibit. We incorporated the first

quarter factor from cell J35 of Table 5A of the Actuarial Memo Rate Exhibit. Again, please note that the

URRT requires factors to be rounded to four decimal places, resulting in small differences.

4. PLAN PREMIUM DEVELOPMENT FOR 21-YEAR OLD NON-TOBACCO USER

Table 11 is populated from other sections of the Rate Exhibits, along with the population by age and

rating area for the Projection Period.

5. PLAN FACTORS

Tables 12, 13, and 14 illustrate the factors used in pricing for age, tobacco, geographic rating area, and

network. The tobacco factors match the previously approved tobacco factors from the 2019 filing.


6. ACTUARIAL CERTIFICATION

I, XXXXXXXXXX, am Director & Actuary of Commercial Markets for the Independence Blue Cross Family of Companies. I am a member of the Society of Actuaries and the American Academy of Actuaries with the education and experience necessary to perform the work necessary and meet the Qualification Standards of the American Academy of Actuaries to render the qualified actuarial opinion contained herein. The developed rates and memorandum have been prepared in conformity with appropriate Actuarial Standards of Practice and the Academy’s Code of Professional Conduct. The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the premium rates and allowable rating factors. Rather, it represents information required by Federal regulation to be provided in support of the review of gross premium rate increases, for certification of qualified health plans for Federally facilitated exchanges, and for certification that the index rate is developed in accordance with Federal regulation and used consistently and only adjusted by the allowable modifiers. I hereby certify that, to the best of my knowledge and judgment, the following:

▪ The projected index rate is: —In compliance with all applicable State and Federal Statutes and Regulations (45 CFR

156.08(d)(1) and 147.106); —Developed in compliance with applicable Actuarial Standards of Practice; —Reasonable in relation to the benefits provided and the population anticipated to be

covered; and —Neither excessive nor deficient.

▪ The index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2) were used to generate plan level rates.

▪ The percent of total premium that represents essential health benefits included in Worksheet 2, Sections III and IV were calculated in accordance with actuarial standards of practice.

▪ The AV Calculator was used to determine the AV Metal Values illustrated in Worksheet 2 of the Part I Unified Rate Review Template for all plans, unless an alternate methodology was required. If an alternate methodology was used to calculate the AV Metal Value for at least one plan offered, a copy of the actuarial certification required by 45 CFR Part 156, §156.135 will be included.

▪ All factor, benefit, and other changes from the prior approved filing have been disclosed in the actuarial memorandum.

▪ New plans cannot be considered modifications of existing plans under the uniform modification standards in 45 CFR 147.106.

▪ The information presented in the PA Actuarial Memorandum and PA Actuarial Memorandum Rate Exhibits is consistent with the information presented in the 2020 Rate Filing Justification.

XXXXXXXXXX XXXXXXXXXX May 21, 2019


PA Rate Template Part IData Relevant to the Rate Filing

Table 0. Identifying Information

Carrier Name: QCC Insurance Company, Inc.Product(s): PPOMarket Segment: Small Group

Rate Effective Date: 1/1/2020 to 12/31/2020Base Period Start Date 1/1/2018 to 12/31/2018Date of Most Recent Membership 2/1/2019

Table 1. Number of Members

Member-months Members Member-months

Experience PeriodCurrent Period

(as of 02-01-2019)Projected Rating Period

Average Age 35.5 36.0 36.0

Total 838,663 71,592 859,104<18 183,284 15,084 181,008

18-24 94,369 7,995 95,940

25-29 59,269 5,185 62,220

30-34 61,320 5,488 65,856

35-39 59,506 5,211 62,532

40-44 57,594 4,927 59,124

45-49 68,006 5,648 67,776

50-54 80,612 6,778 81,336

55-59 84,661 7,326 87,912

60-63 64,173 5,552 66,624

64+ 25,869 2,398 28,776

*Tables 1, 2 and 4 must include data for all non-grandfathered business (ACA compliant and Transitional)

Table 2. Experience Period Claims and Premiums

Earned Premium Paid Claims Ultimate Incurred Claims Member MonthsEstimated Cost Sharing

(Member & HHS)Allowed Claims (Non-Capitated)

Non-EHB portion of Allowed Claims

Total Prescription Drug Rebates* Total EHB Capitation Total Non-EHB Capitation Estimated Risk Adjustment

$ 506,462,338.90 $ 357,703,327.92 $ 363,459,821.47 838,663 $ 81,328,063.18 $ 444,787,884.65 ($10,202,729.92) $ 7,221,960.67 $ 4,294,093.53 11,856,562.46$ Experience Period Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 526.80$ Loss Ratio 70.38%*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Induced Demand* Composite Trend Weight*4.19% 2.86% 0.00% 7.17% 16.88%4.18% 2.86% 0.00% 7.17% 22.63%2.25% 2.86% 0.00% 5.17% 33.54%2.25% 2.86% 0.00% 5.17% 0.00%

2.39% 1.66%0.00% 2.86% 0.00% 2.86% 25.30%

5.35% 100.00%24

1.110* Express Cost, Utilization, Induced Utilization and Weight as percentages** Should = URRT Trend

Table 4. Historical Experience

Month-Year Total Annual Premium Incurred Claims Completion Factors* Ultimate Incurred Claims Members Ultimate Incurred PMPMEstimated Annual Cost Sharing

(Member + HHS)Prescription Drug Rebates**

Allowed Claims (Net of Prescription Drug Rebates)

Allowed PMPM

Jan-15 $ 32,309,094.13 1.0000 $ 32,309,094.13 70,883 $ 455.81 $ - Feb-15 $ 30,811,430.03 1.0000 $ 30,811,430.03 70,886 $ 434.66 $ - Mar-15 $ 34,386,983.59 1.0000 $ 34,386,983.59 71,302 $ 482.27 $ - Apr-15 $ 32,814,106.30 1.0000 $ 32,814,106.30 71,301 $ 460.22 $ -

May-15 $ 33,116,024.58 1.0000 $ 33,116,024.58 71,540 $ 462.90 $ - Jun-15 $ 34,454,919.93 1.0000 $ 34,454,919.93 71,588 $ 481.29 $ - Jul-15 $ 34,287,028.85 1.0000 $ 34,287,028.85 72,000 $ 476.21 $ -

Aug-15 $ 33,017,075.37 1.0000 $ 33,017,075.37 72,128 $ 457.76 $ - Sep-15 $ 34,153,937.57 1.0000 $ 34,153,937.57 72,522 $ 470.95 $ - Oct-15 $ 36,701,611.69 1.0000 $ 36,701,611.69 73,026 $ 502.58 $ - Nov-15 $ 34,484,307.80 1.0000 $ 34,484,307.80 73,230 $ 470.90 $ - Dec-15 $ 36,095,862.16 1.0000 $ 36,095,862.16 74,042 $ 487.51 $ - Jan-16 $ 30,937,923.85 1.0000 $ 30,937,923.85 74,167 $ 417.14 $ - Feb-16 $ 32,165,454.88 1.0000 $ 32,165,454.88 74,253 $ 433.19 $ - Mar-16 $ 34,451,207.60 1.0000 $ 34,451,207.60 74,493 $ 462.48 $ - Apr-16 $ 31,669,954.60 1.0000 $ 31,669,954.60 74,518 $ 425.00 $ -

May-16 $ 33,422,845.51 1.0000 $ 33,422,845.51 74,370 $ 449.41 $ - Jun-16 $ 32,772,282.32 1.0000 $ 32,772,282.32 74,171 $ 441.85 $ - Jul-16 $ 30,719,702.22 1.0000 $ 30,719,702.22 74,031 $ 414.96 $ -


May-17 $ 34,343,315.77 1.0000 $ 34,343,315.77 75,072 $ 457.47 $ - Jun-17 $ 33,025,839.53 1.0000 $ 33,025,839.53 75,013 $ 440.27 $ - Jul-17 $ 31,307,356.70 1.0000 $ 31,307,356.70 74,884 $ 418.08 $ -


May-18 $ 31,270,102.50 0.9973 $ 31,354,317.67 69,118 $ 453.63 $ - Jun-18 $ 28,045,695.53 0.9960 $ 28,157,789.55 68,810 $ 409.21 $ - Jul-18 $ 28,145,952.19 0.9932 $ 28,339,300.81 68,778 $ 412.04 $ -

Aug-18 $ 33,467,526.73 0.9898 $ 33,811,257.63 69,089 $ 489.39 $ - Sep-18 $ 27,584,345.31 0.9828 $ 28,068,316.75 69,431 $ 404.26 $ - Oct-18 $ 32,404,628.05 0.9727 $ 33,314,386.16 69,668 $ 478.19 $ - Nov-18 $ 30,805,952.70 0.9593 $ 32,114,577.11 69,725 $ 460.59 $ - Dec-18 $ 27,948,221.99 0.9269 $ 30,151,561.81 70,727 $ 426.31 $ -

* Express Completion Factor as a percentage**Express Prescription Drug Rebates as a negative number

Service CategoryInpatient HospitalOutpatient Hospital

Total Applied Trend Projection Factor

ProfessionalOther Medical CapitationPrescription DrugsTotal Annual TrendMonths of Trend

$ 428,296,353.00

$ 506,462,338.90 $ 81,328,063.18

$ 467,439,041.68 $ 83,665,627.36

$ 489,254,514.16 $ 90,478,996.55

PA Rate Template Part IIRate Development and ChangeCarrier Name: QCC Insurance Company, Inc.Product(s): PPO

Market Segment: Small Group

Rate Effective Date: 1/1/2020

Table 5. Development of the Projected Index Rate, Market-Adjusted Index Rate, and Total Allowed Claims

Development of the Projected Index Rate Actual Experience Data

Manual Data

Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) PMPM 526.80$ -$ <- Actual Experience PMPM should be consistent with the Index Rate for Experience Period on URRT

Two year trend projection Factor 1.110 1.000

Unadjusted Projected Allowed EHB Claims PMPM 584.63$ -$ For Informational Purposes only - No input required.

Single Risk Pool Adjustment Factors

Change in Morbidity 1.000 <- See URRT Instructions Blended Base Period Unadjusted Claims before Normalization 526.80$ <- Index Rate of Experience Period on URRT

Change in Other 1.013 0.000 Blended Earned Premium 506,462,338.90$

Change in Demographics 1.013 <- See URRT Instructions Blended Loss Ratio 70.38%

Change in Network 1.000

Change in Benefits 1.000 <- See URRT Instructions

Change in Other 1.000 <- See URRT Instructions

Total Adjusted Projected Allowed EHB Claims PMPM 591.94$ -$

Credibidility Factors 100% 0% <- See Instructions

Blended Projected EHB Claims PMPM 591.94$ <- Projected Index Rate

Development of the Market-Adjusted Index Rate and Total Allowed Claims

Adjusted Projected Allowed EHB Claims PMPM 591.94$ <- Index Rate for Projection Period on URRT - Individual or First Quarter Small Group Table 5A. Small Group Projected Index Rate with Quarterly TrendAdjusted Projected Allowed EHB Claims PMPM [will only populate for small group filings] 603.63$ Projected Paid to Allowed Ratio 0.807 Effective Date 1/1/2020 4/1/2020 7/1/2020 10/1/2020 Total Single Risk PoolProjected Paid EHB Claims PMPM 487.07$ # of Member Months Renewing in Quarter 213,616 207,629 207,298 210,120 838,663 Market-wide Adjustments Adjusted Projected Allowed EHB Claims PMPM Q1 591.94$ 591.94$ 591.94$ 591.94$ 591.94$ Projected Risk Adjustment PMPM (14.22)$ Months of Trend - 3 6 9 Projected Paid Exchange User Fees PMPM -$ Annual Trend 5.35% 5.35% 5.35% 5.35%

Single Risk Pool Projected Allowed Claims 591.94$ 599.70$ 607.56$ 615.52$ 603.63$ Market-Adjusted Projected Paid EHB Claims PMPM 501.29$ Quarterly Trend Factor 100.0% 101.3% 102.6% 104.0% 102.0%

2020 Trend Factors by Quarter 0.9806 0.9935 1.0065 1.0197Market-Adjusted Projected Allowed EHB Claims PMPM 621.25$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM 5.98$

Market-Adjusted Projected Paid Total Claims PMPM 506.12$

Market-Adjusted Projected Allowed Total Claims PMPM 627.23$

Table 6. Retention Table 7. Normalized Market-Adjusted Projected Allowed Total Claims

Retention Items - Express in percentages Percentages PMPM Amounts Normalization Factors 2019 2020Administrative Expenses 14.65% $95.69 Average Age Factor 1.494 1.512 General and Claims 8.45% $55.19 Average Geographic Factor 1.000 1.000 Agent/Broker Fees and Commissions 5.40% $35.27 Average Tobacco Factor 1.013 1.013 Quality Improvement Initiatives 0.80% $5.23 Average Benefit Richness (induced demand) 1.000 1.000Taxes and Fees 5.87% $38.31 Average Network Factor 1.000 1.000 RA User Fee 0.03% $0.18 PA Premium Tax (if applicable) 2.00% $13.06 Market-Adjusted Projected Allowed Total Claims PMPM 614.12$ 627.23$ Federal Income Tax 1.14% $7.43 Health Insurance Providers Fee (Prorated for Small Groups only) 2.70% $17.64 Normalized Market-Adjusted Projected Allowed Total Claims PMPM 405.89$ 409.43$

Profit/Contingency (after tax) 2.00% $13.06

Total Retention 22.52% $147.07

Projected Required Revenue PMPM 653.18$

Table 8. Components of Rate Change Table 9. Year-over-Year Data to Support Table 8

Rate Components 2019 2020 Difference Percent Change 2019 2020A. Calibrated Plan Adjusted Index Rate (PMPM) 387.74$ 432.43$ $44.69 11.5% Paid-to-Allowed 0.827 0.807

B. Base period allowed claims before normalization 520.95$ 526.80$ $5.85 1.5% URRT Trend (Total Applied Trend Factor) 1.130 1.110 <- URRT W1, S2 C. Normalization factor component of change (176.64)$ (182.92)$ -$6.29 -1.6% URRT Morbidity 1.000 1.000 <- URRT W1, S2

URRT "Other" 1.023 1.013 <- URRT W1, S2D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 344.31$ 343.88$ (0.44)$ -0.1% Risk Adjustment (6.38)$ 14.22$ <- URRT W1, S3 D2. URRT Trend 44.84$ 37.75$ (7.09)$ -1.8% Exchange User Fee -$ -$ <- URRT W1, S3 D3. URRT Morbidity -$ -$ -$ 0.0% Capitation -$ <- URRT W1, S2 D4. URRT Other 8.96$ 4.77$ (4.18)$ -1.1% D5. Normalized URRT RA/RI on an allowed basis (5.10)$ 11.50$ 16.60$ 4.3% Network 1.000 1.000 D6. Normalized Exchange User Fee on an allowed basis -$ -$ -$ 0.0% Pricing AV 0.827 0.807 <- For 2019 in cell J81, please include a factor equal to the product of the average Pricing AV and the Non-Funding of CSR Adjustment D7. Subtotal - Sum(D1:D6) 393.01$ 397.90$ 4.89$ 1.3% Benefit Richness 1.000 1.000E. Change in Allowable Plan Adjusted Level Components Catastrophic Eligibility 1.000 1.000 E1. Network (0.03)$ -$ 0.03$ 0.0% E2. Pricing AV -67.82736561 (76.83)$ (9.01)$ -2.3% Administrative Expenses 15.20% 14.65% E3. Benefit Richness 0.01$ 0.00$ (0.01)$ 0.0% Taxes and Fees 2.52% 5.87% E4. Catastrophic Eligibility -$ -$ -$ 0.0% Profit and/or Contingency 2.00% 2.00% E5. Subtotal - Sum(E1:E4) (67.85)$ (76.83)$ (8.98)$ -2.3%F. Change in Retention Components F1. Administrative Expenses 58.94$ 63.35$ 4.42$ 1.1% F2. Taxes and Fees 9.77$ 25.36$ 15.59$ 4.0% F3. Profit and/or Contingency 7.75$ 8.65$ 0.89$ 0.2% F4. Subtotal - Sum(F1:F3) 76.46$ 97.36$ 20.90$ 5.4%

G. Change in Miscellaneous Items -$ -$ -$ 0.0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 401.62$ 418.43$ 16.81$ 4.3%

<- For 2019 in cell J81, please include a factor equal to the product of the average Pricing AV and the Non-Funding of CSR Adjustment

PA Rate Template Part IIITable 10. Plan Rates

Age Calibration Factor 1.512Carrier Name: QCC Insurance Company, Inc. Geographic Calibration Factor 1.000Product(s): PPO Tobacco Calibration Factor 1.013Market Segment: Small Group Aggregate Calibration Factor 1.532


Base Period Start Date 1/1/2018Date of Most Recent Membership 2/1/2019

Market Adjusted Index Rate 621.25$

Plan Number

HIOS Plan ID (Standard

Component)

Plan Type (HMO, POS, PPO, EPO,

Indemnity, Other)1/1/2019 Plan

Marketing Name

Existing, Modified, New, Discontinued &

Mapped, Discontinued & Not Mapped (E,M,N,DM,

DNM) for 2020

1/1/2020 Plan HIOS Plan ID (If 1/1/2019 Plan Discontinued &

Mapped) Metallic Tier

Metallic Tier Actuarial

Value

Standard AV, Approach (1), Approach (2)

Exchange On/Off or

Off

Pricing AV (company-

determined AV)

Benefit Richness (induced demand)

Benefits in addition to

EHBProvider Network

Catastrophic Eligibility

Non-Funding of CSR

Adjustment Pure Premium Admin Costs

Taxes & Fees (not including Exchange

fees)Profit or

Contingency

Total Covered Lives

Mapped into 2020 Plans @ 02-01-

2019Total Policyholders

@ 02-01-2019

2019 Calibrated Plan Adjusted

Index Rate PMPM

2020 Calibrated Plan Adjusted

Index Rate PMPM

Proposed Rate Change

Compared to Prior 12 months

% of Total Covered Lives 1 2 3 4 5 6 7 8 9 Total

2020 Continued/ Discontined

Plans Indicator

Totals 0.781 0.807 1.000 1.010 1.000 1.000 1.000 513.30$ 14.7% 5.9% 2.0% 71,592 9,525 387.74$ 432.43$ 11.5% - - - - - - - 71,592 - 71,592

Transitional Plans TRANSITIONAL N/A TRANSITIONAL DNM TRANSITIONAL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A - N/A N/A N/A N/A - 0

Plan 1 31609PA0150025 PPOPersonal Choice PPO Platinum Preferred $10/$20/$150 E Platinum 0.9006 Approach 1 Off 0.935 1.184 1.010 1.000 1.000 1.000 $695.13 14.7% 5.9% 2.0% 7,498 1,052 520.28$ 585.61$ 12.6% 10.5% 7,498 7,498 1

Plan 2 31609PA0150026 PPOPersonal Choice PPO Platinum Preferred $20/$40/$150 E Platinum 0.8827 Approach 1 Off 0.924 1.142 1.010 1.000 1.000 1.000 $661.66 14.7% 5.9% 2.0% 12,004 1,527 497.21$ 557.41$ 12.1% 16.8% 12,004 12,004 1

Plan 3 31609PA0150027 PPOPersonal Choice PPO Gold Preferred $35/$70/$600 E Gold 0.8157 Approach 1 Off 0.853 0.988 1.010 1.000 1.000 1.000 $528.48 14.7% 5.9% 2.0% 13,795 1,927 406.09$ 445.22$ 9.6% 19.3% 13,795 13,795 1

Plan 4 31609PA0150028 PPOPersonal Choice PPO Gold Classic $1,500/$15/$30/80% E Gold 0.796 Approach 1 Off 0.774 1.068 1.010 1.000 1.000 1.000 $518.89 14.7% 5.9% 2.0% 1,741 292 395.53$ 437.13$ 10.5% 2.4% 1,741 1,741 1

Plan 5 31609PA0150029 PPOPersonal Choice PPO Silver Classic $3,250/$30/$60/70% E Silver 0.7191 Approach 1 Off 0.732 0.923 1.010 1.000 1.000 1.000 $423.96 14.7% 5.9% 2.0% 2,451 442 321.33$ 357.17$ 11.2% 3.4% 2,451 2,451 1

Plan 6 31609PA0150030 PPOPersonal Choice PPO Platinum HSA-50 $1,600/100% E Platinum 0.9004 Standard AV Off 0.906 1.038 1.010 1.000 1.000 1.000 $590.15 14.7% 5.9% 2.0% 1,030 140 450.06$ 497.17$ 10.5% 1.4% 1,030 1,030 1

Plan 7 31609PA0150031 PPOPersonal Choice PPO Gold HSA-25 $2,400/90% E Gold 0.7933 Standard AV Off 0.819 0.958 1.010 1.000 1.000 1.000 $492.04 14.7% 5.9% 2.0% 1,240 183 372.83$ 414.52$ 11.2% 1.7% 1,240 1,240 1

Plan 8 31609PA0150032 PPOPersonal Choice PPO Gold HSA-0 $1,900/100% E Gold 0.7857 Standard AV Off 0.822 1.110 1.010 1.000 1.000 1.000 $572.36 14.7% 5.9% 2.0% 2,023 266 431.50$ 482.18$ 11.7% 2.8% 2,023 2,023 1

Plan 9 31609PA0150033 PPOPersonal Choice PPO Gold HSA-25 $2,600/80% E Gold 0.7849 Standard AV Off 0.890 0.800 1.010 1.000 1.000 1.000 $446.82 14.7% 5.9% 2.0% 106 17 333.48$ 376.42$ 12.9% 0.1% 106 106 1

Plan 10 31609PA0150034 PPOPersonal Choice PPO Silver HSA-0 $2,100/70% E Silver 0.7104 Standard AV Off 0.761 0.881 1.010 1.000 1.000 1.000 $420.83 14.7% 5.9% 2.0% 1,064 155 315.30$ 354.53$ 12.4% 1.5% 1,064 1,064 1


Plan 12 31609PA0150036 PPOPersonal Choice PPO Bronze HSA-0 $5,200/50% E Bronze 0.6284 Standard AV Off 0.622 0.813 1.010 1.000 1.000 1.000 $317.02 14.7% 5.9% 2.0% 7,585 858 237.49$ 267.07$ 12.5% 10.6% 7,585 7,585 1

Plan 13 31609PA0150037 PPOPersonal Choice PPO Bronze HSA-0 $6,750/100% E Bronze 0.6208 Standard AV Off 0.626 0.870 1.010 1.000 1.000 1.000 $341.35 14.7% 5.9% 2.0% 4,128 522 254.13$ 287.57$ 13.2% 5.8% 4,128 4,128 1

Plan 14 31609PA0150039 PPOPersonal Choice PPO Gold HRA-25 $3,200/100% E Gold 0.8162 Standard AV Off 0.811 1.021 1.010 1.000 1.000 1.000 $519.71 14.7% 5.9% 2.0% 793 44 392.00$ 437.83$ 11.7% 1.1% 793 793 1

Plan 15 31609PA0150047 PPOPersonal Choice PPO Gold Classic $2,500 $40/$80/100% E Gold 0.8039 Approach 1 Off 0.812 1.017 1.010 1.000 1.000 1.000 $518.40 14.7% 5.9% 2.0% 3,627 528 386.91$ 436.73$ 12.9% 5.1% 3,627 3,627 1

Plan 16 31609PA0150048 PPOPersonal Choice PPO Silver Classic $4,750/$50/$100/90% E Silver 0.7156 Approach 1 Off 0.742 0.785 1.010 1.000 1.000 1.000 $365.53 14.7% 5.9% 2.0% 1,406 261 278.56$ 307.94$ 10.5% 2.0% 1,406 1,406 1

Plan 17 31609PA0150049 PPOPersonal Choice PPO Silver Secure $4,500/$35/$70/$600 E Silver 0.7193 Approach 1 Off 0.728 0.823 1.010 1.000 1.000 1.000 $375.80 14.7% 5.9% 2.0% 2,724 409 290.14$ 316.59$ 9.1% 3.8% 2,724 2,724 1


Plan 19 31609PA0170001 EPOPersonal Choice EPO Silver HSA-0 $3,000/80% E Silver 0.6945 Standard AV Off 0.722 0.903 1.010 0.950 1.000 1.000 $388.86 14.7% 5.9% 2.0% 696 81 291.38$ 327.59$ 12.4% 1.0% 696 696 1

02-01-2019 Number of Covered Lives by Rating Area

Calibration Total Covered Lives @ 02-01-2019

71,592

45 CFR Part 156.8 (d) (2) Allowable Factors

PA Rate Template Part IV B - Small Group AnnualTable 11. Plan Premium Development for 21-Year-Old Non-Tobacco User

Carrier Name: QCC Insurance Company, Inc.Product(s): PPOMarket Segment: Small GroupRate Effective Date: 1/1/2020

Plan NumberHIOS Plan ID (Standard

Component)1/1/2019 Plan

Marketing Name

Discontinued, New, Modified,

Existing (D,N,M,E) for

2020

1/1/2020 Plan HIOS Plan ID (If 1/1/2019 Plan

Discontinued & Mapped)Metallic

Tier

Exchange On/Off or

Off 1 2 3 4 5 6 7 8 9

Average (weighted

by enrollment by rating

area) 1 2 3 4 5 6 7 8 9

Average (weighted


area) 1 2 3 4 5 6 7 8 9

Average (weighted


area) 1 2 3 4 5 6 7 8 9

Average (weighted


area) 1 2 3 4 5 6 7 8 9

Average (weighted


area) 1 2 3 4 5 6 7 8 9

Average (weighted


area)

Totals -$ -$ -$ -$ -$ -$ -$ 402.56$ -$ 402.56$ -$ -$ -$ -$ -$ -$ -$ 424.06$ -$ 424.06$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.3% 0.0% 5.3% -$ -$ -$ -$ -$ -$ -$ 429.61$ -$ 429.61$ -$ -$ -$ -$ -$ -$ -$ 435.24$ -$ 435.24$ -$ -$ -$ -$ -$ -$ -$ 440.95$ -$ 440.95$

Plan 1 31609PA0150025Personal Choice PPO Platinum Preferred $10/$20/$150E 0 Platinum Off 540.17$ 540.17$ -$ -$ -$ -$ -$ -$ -$ 574.27$ -$ 574.27$ 6.3% 6.3% -$ -$ -$ -$ -$ -$ -$ 581.79$ -$ 581.79$ -$ -$ -$ -$ -$ -$ -$ 589.42$ -$ 589.42$ -$ -$ -$ -$ -$ -$ -$ 597.14$ -$ 597.14$ Plan 2 31609PA0150026Personal Choice PPO Platinum Preferred $20/$40/$150E 0 Platinum Off 516.22$ 516.22$ -$ -$ -$ -$ -$ -$ -$ 546.62$ -$ 546.62$ 5.9% 5.9% -$ -$ -$ -$ -$ -$ -$ 553.79$ -$ 553.79$ -$ -$ -$ -$ -$ -$ -$ 561.04$ -$ 561.04$ -$ -$ -$ -$ -$ -$ -$ 568.39$ -$ 568.39$ Plan 3 31609PA0150027Personal Choice PPO Gold Preferred $35/$70/$600E 0 Gold Off 421.61$ 421.61$ -$ -$ -$ -$ -$ -$ -$ 436.60$ -$ 436.60$ 3.6% 3.6% -$ -$ -$ -$ -$ -$ -$ 442.32$ -$ 442.32$ -$ -$ -$ -$ -$ -$ -$ 448.11$ -$ 448.11$ -$ -$ -$ -$ -$ -$ -$ 453.99$ -$ 453.99$ Plan 4 31609PA0150028Personal Choice PPO Gold Classic $1,500/$15/$30/80%E 0 Gold Off 410.65$ 410.65$ -$ -$ -$ -$ -$ -$ -$ 428.67$ -$ 428.67$ 4.4% 4.4% -$ -$ -$ -$ -$ -$ -$ 434.29$ -$ 434.29$ -$ -$ -$ -$ -$ -$ -$ 439.98$ -$ 439.98$ -$ -$ -$ -$ -$ -$ -$ 445.74$ -$ 445.74$ Plan 5 31609PA0150029Personal Choice PPO Silver Classic $3,250/$30/$60/70%E 0 Silver Off 333.61$ 333.61$ -$ -$ -$ -$ -$ -$ -$ 350.25$ -$ 350.25$ 5.0% 5.0% -$ -$ -$ -$ -$ -$ -$ 354.84$ -$ 354.84$ -$ -$ -$ -$ -$ -$ -$ 359.49$ -$ 359.49$ -$ -$ -$ -$ -$ -$ -$ 364.20$ -$ 364.20$ Plan 6 31609PA0150030Personal Choice PPO Platinum HSA-50 $1,600/100%E 0 Platinum Off 467.27$ 467.27$ -$ -$ -$ -$ -$ -$ -$ 487.54$ -$ 487.54$ 4.3% 4.3% -$ -$ -$ -$ -$ -$ -$ 493.93$ -$ 493.93$ -$ -$ -$ -$ -$ -$ -$ 500.41$ -$ 500.41$ -$ -$ -$ -$ -$ -$ -$ 506.96$ -$ 506.96$ Plan 7 31609PA0150031Personal Choice PPO Gold HSA-25 $2,400/90%E 0 Gold Off 387.08$ 387.08$ -$ -$ -$ -$ -$ -$ -$ 406.49$ -$ 406.49$ 5.0% 5.0% -$ -$ -$ -$ -$ -$ -$ 411.82$ -$ 411.82$ -$ -$ -$ -$ -$ -$ -$ 417.22$ -$ 417.22$ -$ -$ -$ -$ -$ -$ -$ 422.68$ -$ 422.68$ Plan 8 31609PA0150032Personal Choice PPO Gold HSA-0 $1,900/100%E 0 Gold Off 447.99$ 447.99$ -$ -$ -$ -$ -$ -$ -$ 472.85$ -$ 472.85$ 5.5% 5.5% -$ -$ -$ -$ -$ -$ -$ 479.04$ -$ 479.04$ -$ -$ -$ -$ -$ -$ -$ 485.32$ -$ 485.32$ -$ -$ -$ -$ -$ -$ -$ 491.68$ -$ 491.68$ Plan 9 31609PA0150033Personal Choice PPO Gold HSA-25 $2,600/80%E 0 Gold Off 346.23$ 346.23$ -$ -$ -$ -$ -$ -$ -$ 369.13$ -$ 369.13$ 6.6% 6.6% -$ -$ -$ -$ -$ -$ -$ 373.97$ -$ 373.97$ -$ -$ -$ -$ -$ -$ -$ 378.87$ -$ 378.87$ -$ -$ -$ -$ -$ -$ -$ 383.83$ -$ 383.83$ Plan 10 31609PA0150034Personal Choice PPO Silver HSA-0 $2,100/70%E 0 Silver Off 327.35$ 327.35$ -$ -$ -$ -$ -$ -$ -$ 347.66$ -$ 347.66$ 6.2% 6.2% -$ -$ -$ -$ -$ -$ -$ 352.22$ -$ 352.22$ -$ -$ -$ -$ -$ -$ -$ 356.83$ -$ 356.83$ -$ -$ -$ -$ -$ -$ -$ 361.51$ -$ 361.51$ Plan 11 31609PA0150035Personal Choice PPO Silver HSA-0 $2,700/90% E 0 Silver Off 363.53$ 363.53$ -$ -$ -$ -$ -$ -$ -$ 382.72$ -$ 382.72$ 5.3% 5.3% -$ -$ -$ -$ -$ -$ -$ 387.73$ -$ 387.73$ -$ -$ -$ -$ -$ -$ -$ 392.81$ -$ 392.81$ -$ -$ -$ -$ -$ -$ -$ 397.96$ -$ 397.96$ Plan 12 31609PA0150036Personal Choice PPO Bronze HSA-0 $5,200/50%E 0 Bronze Off 246.57$ 246.57$ -$ -$ -$ -$ -$ -$ -$ 261.90$ -$ 261.90$ 6.2% 6.2% -$ -$ -$ -$ -$ -$ -$ 265.33$ -$ 265.33$ -$ -$ -$ -$ -$ -$ -$ 268.81$ -$ 268.81$ -$ -$ -$ -$ -$ -$ -$ 272.33$ -$ 272.33$ Plan 13 31609PA0150037Personal Choice PPO Bronze HSA-0 $6,750/100%E 0 Bronze Off 263.84$ 263.84$ -$ -$ -$ -$ -$ -$ -$ 282.00$ -$ 282.00$ 6.9% 6.9% -$ -$ -$ -$ -$ -$ -$ 285.69$ -$ 285.69$ -$ -$ -$ -$ -$ -$ -$ 289.44$ -$ 289.44$ -$ -$ -$ -$ -$ -$ -$ 293.23$ -$ 293.23$ Plan 14 31609PA0150039Personal Choice PPO Gold HRA-25 $3,200/100%E 0 Gold Off 406.99$ 406.99$ -$ -$ -$ -$ -$ -$ -$ 429.35$ -$ 429.35$ 5.5% 5.5% -$ -$ -$ -$ -$ -$ -$ 434.98$ -$ 434.98$ -$ -$ -$ -$ -$ -$ -$ 440.68$ -$ 440.68$ -$ -$ -$ -$ -$ -$ -$ 446.45$ -$ 446.45$ Plan 15 31609PA0150047Personal Choice PPO Gold Classic $2,500 $40/$80/100%E 0 Gold Off 401.70$ 401.70$ -$ -$ -$ -$ -$ -$ -$ 428.27$ -$ 428.27$ 6.6% 6.6% -$ -$ -$ -$ -$ -$ -$ 433.88$ -$ 433.88$ -$ -$ -$ -$ -$ -$ -$ 439.57$ -$ 439.57$ -$ -$ -$ -$ -$ -$ -$ 445.33$ -$ 445.33$ Plan 16 31609PA0150048Personal Choice PPO Silver Classic $4,750/$50/$100/90%E 0 Silver Off 289.21$ 289.21$ -$ -$ -$ -$ -$ -$ -$ 301.98$ -$ 301.98$ 4.4% 4.4% -$ -$ -$ -$ -$ -$ -$ 305.93$ -$ 305.93$ -$ -$ -$ -$ -$ -$ -$ 309.94$ -$ 309.94$ -$ -$ -$ -$ -$ -$ -$ 314.00$ -$ 314.00$ Plan 17 31609PA0150049Personal Choice PPO Silver Secure $4,500/$35/$70/$600E 0 Silver Off 301.24$ 301.24$ -$ -$ -$ -$ -$ -$ -$ 310.46$ -$ 310.46$ 3.1% 3.1% -$ -$ -$ -$ -$ -$ -$ 314.52$ -$ 314.52$ -$ -$ -$ -$ -$ -$ -$ 318.65$ -$ 318.65$ -$ -$ -$ -$ -$ -$ -$ 322.82$ -$ 322.82$ Plan 18 31609PA0150050Personal Choice PPO Silver HSA-0 $3,200/100%E 0 Silver Off 364.01$ 364.01$ -$ -$ -$ -$ -$ -$ -$ 385.16$ -$ 385.16$ 5.8% 5.8% -$ -$ -$ -$ -$ -$ -$ 390.21$ -$ 390.21$ -$ -$ -$ -$ -$ -$ -$ 395.32$ -$ 395.32$ -$ -$ -$ -$ -$ -$ -$ 400.51$ -$ 400.51$ Plan 19 31609PA0170001Personal Choice EPO Silver HSA-0 $3,000/80%E 0 Silver Off 302.52$ 302.52$ -$ -$ -$ -$ -$ -$ -$ 321.25$ -$ 321.25$ 6.2% 6.2% -$ -$ -$ -$ -$ -$ -$ 325.46$ -$ 325.46$ -$ -$ -$ -$ -$ -$ -$ 329.73$ -$ 329.73$ -$ -$ -$ -$ -$ -$ -$ 334.05$ -$ 334.05$

Quarter 3 2020, 21-year-old Non-Tobacco Premium PMPM Quarter 4 2020, 21-year-old Non-Tobacco Premium PMPM

These cells auto-fill using the data entered in Table 10.

Quarter 1 2019, 21-year-old Non-Tobacco Premium PMPM Quarter 1 2020, 21-year-old Non-Tobacco Premium PMPM Change in Quarter 1, 21-year-old Non-Tobacco Premium PMPM Quarter 2 2020, 21-year-old Non-Tobacco Premium PMPM

PA Rate Quarterly Template Part VConsumer Factors

Carrier Name: QCC Insurance Company, Inc.

Product(s): PPO

Market Segment: Small Group


Table 12. Age and Tobacco Factors Table 13. Geographic Factors

Age Band

Age Factor

Tobacco Factor

Age Band

Age Factor

Tobacco Factor

Area CountiesCurrent Factor

Proposed Factor

0-14 0.765 40 1.278 1.225 Rating Area 115 0.833 41 1.302 1.225 Rating Area 2 16 0.859 42 1.325 1.225 Rating Area 317 0.885 43 1.357 1.225 Rating Area 4 18 0.913 1.000 44 1.397 1.225 Rating Area 519 0.941 1.000 45 1.444 1.225 Rating Area 620 0.970 1.000 46 1.500 1.225 Rating Area 7

21 1.000 1.125 47 1.563 1.225 Rating Area 8Bucks, Chester, Delaware, Philadelphia, Montgomery

1.000 1.000

22 1.000 1.125 48 1.635 1.225 Rating Area 923 1.000 1.125 49 1.706 1.22524 1.000 1.125 50 1.786 1.375

25 1.004 1.125 51 1.865 1.375 Table 14. Network Factors26 1.024 1.125 52 1.952 1.37527 1.048 1.125 53 2.040 1.375

28 1.087 1.125 54 2.135 1.375 Network Name Rating AreaCurrent Factor

Proposed Factor

DOH Approval

Date29 1.119 1.125 55 2.230 1.375 PPO Rating Area 8 1.000 1 5/6/199730 1.135 1.175 56 2.333 1.375 EPO Rating Area 8 0.950 0.950 5/6/199731 1.159 1.175 57 2.437 1.37532 1.183 1.175 58 2.548 1.37533 1.198 1.175 59 2.603 1.37534 1.214 1.175 60 2.714 1.37535 1.222 1.175 61 2.810 1.37536 1.230 1.175 62 2.873 1.37537 1.238 1.175 63 2.952 1.37538 1.246 1.175 64+ 3.000 1.37539 1.262 1.175

*PA follows the federal default age curve.

Projection Period Age and Tobacco Factors Geographic Area Factors

Projecion Period Network Factors

Company Name:Market:Product:

Effective Date of Rates: Ending date of Rates:

HIOS Plan ID (On Exchange)=>HIOS Plan ID (Off Exchange)=>

Plan Marketing Name =>Form # =>

Rating Area =>Network =>

Metal =>Deductible => $0 $0 $0

Coinsurance => 0% 0% 0%Copays => $10/$20 $20/$40 $40/$80

OOP Maximum => $4,500 $4,500 $8,150Pediatric Dental (Yes/No) =>

Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco0-14 $439.32 $439.32 $418.16 $418.16 $334.00 $334.0015 $478.37 $478.37 $455.33 $455.33 $363.69 $363.6916 $493.30 $493.30 $469.55 $469.55 $375.04 $375.0417 $508.23 $508.23 $483.76 $483.76 $386.39 $386.3918 $524.31 $524.31 $499.06 $499.06 $398.62 $398.6219 $540.39 $540.39 $514.37 $514.37 $410.84 $410.8420 $557.04 $557.04 $530.22 $530.22 $423.50 $423.5021 $574.27 $646.05 $546.62 $614.95 $436.60 $491.1822 $574.27 $646.05 $546.62 $614.95 $436.60 $491.1823 $574.27 $646.05 $546.62 $614.95 $436.60 $491.1824 $574.27 $646.05 $546.62 $614.95 $436.60 $491.1825 $576.57 $648.64 $548.81 $617.41 $438.35 $493.1426 $588.05 $661.56 $559.74 $629.71 $447.08 $502.9627 $601.83 $677.06 $572.86 $644.46 $457.56 $514.7528 $624.23 $702.26 $594.18 $668.45 $474.58 $533.9129 $642.61 $722.93 $611.67 $688.13 $488.56 $549.6230 $651.80 $765.86 $620.41 $728.99 $495.54 $582.2631 $665.58 $782.06 $633.53 $744.40 $506.02 $594.5732 $679.36 $798.25 $646.65 $759.82 $516.50 $606.8833 $687.98 $808.37 $654.85 $769.45 $523.05 $614.5834 $697.16 $819.17 $663.60 $779.73 $530.03 $622.7935 $701.76 $824.57 $667.97 $784.86 $533.53 $626.8936 $706.35 $829.96 $672.34 $790.00 $537.02 $631.0037 $710.95 $835.36 $676.72 $795.14 $540.51 $635.1038 $715.54 $840.76 $681.09 $800.28 $544.00 $639.2039 $724.73 $851.56 $689.83 $810.56 $550.99 $647.4140 $733.92 $899.05 $698.58 $855.76 $557.97 $683.5241 $747.70 $915.93 $711.70 $871.83 $568.45 $696.3642 $760.91 $932.11 $724.27 $887.23 $578.50 $708.6643 $779.28 $954.62 $741.76 $908.66 $592.47 $725.7744 $802.26 $982.76 $763.63 $935.44 $609.93 $747.1645 $829.25 $1,015.83 $789.32 $966.92 $630.45 $772.3046 $861.41 $1,055.22 $819.93 $1,004.41 $654.90 $802.2547 $897.58 $1,099.54 $854.37 $1,046.60 $682.41 $835.9548 $938.93 $1,150.19 $893.72 $1,094.81 $713.84 $874.4649 $979.70 $1,200.14 $932.53 $1,142.35 $744.84 $912.4350 $1,025.65 $1,410.26 $976.26 $1,342.36 $779.77 $1,072.1851 $1,071.01 $1,472.64 $1,019.45 $1,401.74 $814.26 $1,119.6152 $1,120.98 $1,541.34 $1,067.00 $1,467.13 $852.24 $1,171.8353 $1,171.51 $1,610.83 $1,115.10 $1,533.27 $890.66 $1,224.6654 $1,226.07 $1,685.84 $1,167.03 $1,604.67 $932.14 $1,281.6955 $1,280.62 $1,760.86 $1,218.96 $1,676.07 $973.62 $1,338.7256 $1,339.77 $1,842.19 $1,275.26 $1,753.49 $1,018.59 $1,400.5657 $1,399.50 $1,924.31 $1,332.11 $1,831.66 $1,063.99 $1,462.9958 $1,463.24 $2,011.95 $1,392.79 $1,915.08 $1,112.46 $1,529.6359 $1,494.82 $2,055.38 $1,422.85 $1,956.42 $1,136.47 $1,562.6560 $1,558.57 $2,143.03 $1,483.53 $2,039.85 $1,184.93 $1,629.2861 $1,613.70 $2,218.84 $1,536.00 $2,112.00 $1,226.85 $1,686.9162 $1,649.88 $2,268.58 $1,570.44 $2,159.35 $1,254.35 $1,724.7363 $1,695.25 $2,330.96 $1,613.62 $2,218.73 $1,288.84 $1,772.16

64+ $1,722.81 $2,368.86 $1,639.86 $2,254.81 $1,309.80 $1,800.98

31609PA0150026 31609PA0150027

Personal Choice NetworkGold

16884.WR-I Rev. 1.2016884.WR-I Rev. 1.20

PlatinumPersonal Choice Network

88

YesYes

Personal Choice PPO Gold Preferred $40/$80/$600Personal Choice PPO Platinum Preferred $20/$40/$250

QCC Insurance Company, Inc.Small Group

PPOJanuary 1, 2020

Yes

Personal Choice PPO Platinum Preferred $10/$20/$200

Personal Choice NetworkPlatinum

8

31609PA0150025

16884.WR-I Rev. 1.20


Effective Date of Rates:




Metal =>Deductible =>

Coinsurance =>Copays =>

OOP Maximum =>Pediatric Dental (Yes/No) =>

Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$3,750 $1,80030% 0%

$20 no ded/$40 no ded $30 no ded/$60 no ded$6,900

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$327.93 $327.93 $267.94 $267.94 $372.97 $372.97$357.08 $357.08 $291.76 $291.76 $406.12 $406.12$368.23 $368.23 $300.86 $300.86 $418.80 $418.80$379.37 $379.37 $309.97 $309.97 $431.47 $431.47$391.38 $391.38 $319.78 $319.78 $445.12 $445.12$403.38 $403.38 $329.59 $329.59 $458.78 $458.78$415.81 $415.81 $339.74 $339.74 $472.91 $472.91$428.67 $482.25 $350.25 $394.03 $487.54 $548.48$428.67 $482.25 $350.25 $394.03 $487.54 $548.48$428.67 $482.25 $350.25 $394.03 $487.54 $548.48$428.67 $482.25 $350.25 $394.03 $487.54 $548.48$430.38 $484.18 $351.65 $395.61 $489.49 $550.68$438.96 $493.83 $358.66 $403.49 $499.24 $561.65$449.25 $505.40 $367.06 $412.94 $510.94 $574.81$465.96 $524.21 $380.72 $428.31 $529.96 $596.20$479.68 $539.64 $391.93 $440.92 $545.56 $613.75$486.54 $571.69 $397.53 $467.10 $553.36 $650.20$496.83 $583.77 $405.94 $476.98 $565.06 $663.94$507.12 $595.86 $414.35 $486.86 $576.76 $677.69$513.55 $603.42 $419.60 $493.03 $584.07 $686.29$520.41 $611.48 $425.20 $499.61 $591.87 $695.45$523.83 $615.51 $428.01 $502.91 $595.77 $700.03$527.26 $619.54 $430.81 $506.20 $599.67 $704.62$530.69 $623.56 $433.61 $509.49 $603.57 $709.20$534.12 $627.59 $436.41 $512.78 $607.47 $713.78$540.98 $635.65 $442.02 $519.37 $615.28 $722.95$547.84 $671.10 $447.62 $548.33 $623.08 $763.27$558.13 $683.71 $456.03 $558.63 $634.78 $777.60$567.99 $695.78 $464.08 $568.50 $645.99 $791.34$581.71 $712.59 $475.29 $582.23 $661.59 $810.45$598.85 $733.59 $489.30 $599.39 $681.09 $834.34$619.00 $758.27 $505.76 $619.56 $704.01 $862.41$643.01 $787.68 $525.38 $643.58 $731.31 $895.85$670.01 $820.76 $547.44 $670.61 $762.03 $933.48$700.88 $858.57 $572.66 $701.51 $797.13 $976.48$731.31 $895.86 $597.53 $731.97 $831.74 $1,018.89$765.60 $1,052.71 $625.55 $860.13 $870.75 $1,197.28$799.47 $1,099.27 $653.22 $898.17 $909.26 $1,250.24$836.76 $1,150.55 $683.69 $940.07 $951.68 $1,308.56$874.49 $1,202.42 $714.51 $982.45 $994.58 $1,367.55$915.21 $1,258.41 $747.78 $1,028.20 $1,040.90 $1,431.23$955.93 $1,314.41 $781.06 $1,073.95 $1,087.21 $1,494.92

$1,000.09 $1,375.12 $817.13 $1,123.56 $1,137.43 $1,563.97$1,044.67 $1,436.42 $853.56 $1,173.64 $1,188.13 $1,633.69$1,092.25 $1,501.85 $892.44 $1,227.10 $1,242.25 $1,708.10$1,115.83 $1,534.26 $911.70 $1,253.59 $1,269.07 $1,744.97$1,163.41 $1,599.69 $950.58 $1,307.05 $1,323.18 $1,819.38$1,204.56 $1,656.27 $984.20 $1,353.28 $1,369.99 $1,883.73$1,231.57 $1,693.41 $1,006.27 $1,383.62 $1,400.70 $1,925.97$1,265.43 $1,739.97 $1,033.94 $1,421.66 $1,439.22 $1,978.92$1,286.01 $1,768.26 $1,050.75 $1,444.78 $1,462.62 $2,011.10

0% after ded

Yes

Personal Choice Network8

16884.WR-I Rev. 1.20Personal Choice PPO Platinum HSA-50 $1,800/100%

31609PA0150030

Yes

16884.WR-I Rev. 1.208

31609PA0150028

$6,500

Personal Choice PPO Gold Classic $1,500/$20/$40/80%

$1,50020%

GoldPersonal Choice Network

Platinum

March 31, 2020

$8,150Yes

Personal Choice PPO Silver Classic $3,750/$30/$60/70%16884.WR-I Rev. 1.20

8Personal Choice Network

Silver

31609PA0150029









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$2,400 $2,10010% 0%

$25/$50 20% after ded$6,900 $6,900 $6,900

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$310.96 $310.96 $361.73 $361.73 $282.38 $282.38$338.61 $338.61 $393.88 $393.88 $307.49 $307.49$349.17 $349.17 $406.18 $406.18 $317.08 $317.08$359.74 $359.74 $418.47 $418.47 $326.68 $326.68$371.13 $371.13 $431.71 $431.71 $337.02 $337.02$382.51 $382.51 $444.95 $444.95 $347.35 $347.35$394.30 $394.30 $458.66 $458.66 $358.06 $358.06$406.49 $457.30 $472.85 $531.96 $369.13 $415.27$406.49 $457.30 $472.85 $531.96 $369.13 $415.27$406.49 $457.30 $472.85 $531.96 $369.13 $415.27$406.49 $457.30 $472.85 $531.96 $369.13 $415.27$408.12 $459.13 $474.74 $534.08 $370.61 $416.93$416.25 $468.28 $484.20 $544.72 $377.99 $425.24$426.00 $479.25 $495.55 $557.49 $386.85 $435.20$441.85 $497.09 $513.99 $578.24 $401.24 $451.40$454.86 $511.72 $529.12 $595.26 $413.06 $464.69$461.37 $542.11 $536.68 $630.60 $418.96 $492.28$471.12 $553.57 $548.03 $643.94 $427.82 $502.69$480.88 $565.03 $559.38 $657.27 $436.68 $513.10$486.98 $572.20 $566.47 $665.61 $442.22 $519.61$493.48 $579.84 $574.04 $674.50 $448.12 $526.55$496.73 $583.66 $577.82 $678.94 $451.08 $530.02$499.98 $587.48 $581.61 $683.39 $454.03 $533.49$503.23 $591.30 $585.39 $687.83 $456.98 $536.95$506.49 $595.12 $589.17 $692.28 $459.94 $540.42$512.99 $602.76 $596.74 $701.17 $465.84 $547.36$519.49 $636.38 $604.30 $740.27 $471.75 $577.89$529.25 $648.33 $615.65 $754.17 $480.61 $588.74$538.60 $659.78 $626.53 $767.49 $489.10 $599.14$551.61 $675.72 $641.66 $786.03 $500.91 $613.61$567.87 $695.64 $660.57 $809.20 $515.67 $631.70$586.97 $719.04 $682.80 $836.42 $533.02 $652.95$609.74 $746.93 $709.28 $868.86 $553.70 $678.28$635.34 $778.30 $739.06 $905.35 $576.95 $706.76$664.61 $814.15 $773.11 $947.06 $603.53 $739.32$693.47 $849.50 $806.68 $988.19 $629.74 $771.43$725.99 $998.24 $844.51 $1,161.20 $659.27 $906.49$758.10 $1,042.39 $881.87 $1,212.56 $688.43 $946.59$793.47 $1,091.02 $923.00 $1,269.13 $720.54 $990.74$829.24 $1,140.20 $964.61 $1,326.34 $753.03 $1,035.41$867.86 $1,193.30 $1,009.53 $1,388.11 $788.09 $1,083.63$906.47 $1,246.40 $1,054.46 $1,449.88 $823.16 $1,131.84$948.34 $1,303.97 $1,103.16 $1,516.84 $861.18 $1,184.12$990.62 $1,362.10 $1,152.34 $1,584.46 $899.57 $1,236.91

$1,035.74 $1,424.14 $1,204.82 $1,656.63 $940.54 $1,293.25$1,058.09 $1,454.88 $1,230.83 $1,692.39 $960.85 $1,321.16$1,103.21 $1,516.92 $1,283.31 $1,764.56 $1,001.82 $1,377.50$1,142.24 $1,570.58 $1,328.71 $1,826.97 $1,037.26 $1,426.23$1,167.85 $1,605.79 $1,358.50 $1,867.93 $1,060.51 $1,458.20$1,199.96 $1,649.94 $1,395.85 $1,919.30 $1,089.67 $1,498.30$1,219.47 $1,676.77 $1,418.55 $1,950.51 $1,107.39 $1,522.66

0% after ded

Yes Yes Yes

20%$2,600

Personal Choice Network Personal Choice Network Personal Choice Network8 8 8

16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20Personal Choice PPO Gold HSA-25 $2,400/$25/$50/90%Personal Choice PPO Gold HSA-0 $2,100/100%Personal Choice PPO Gold HSA-25 $2,600/80%

31609PA0150031 31609PA0150032 31609PA0150033

16884.WR-I Rev. 1.20

Gold Gold Gold









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$2,100 $3,00030% 10%

30% after ded 10% after ded 50% after ded$6,900 $6,900 $6,900

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$265.96 $265.96 $292.78 $292.78 $200.35 $200.35$289.60 $289.60 $318.81 $318.81 $218.16 $218.16$298.64 $298.64 $328.76 $328.76 $224.97 $224.97$307.68 $307.68 $338.71 $338.71 $231.78 $231.78$317.41 $317.41 $349.42 $349.42 $239.11 $239.11$327.15 $327.15 $360.14 $360.14 $246.45 $246.45$337.23 $337.23 $371.24 $371.24 $254.04 $254.04$347.66 $391.12 $382.72 $430.56 $261.90 $294.64$347.66 $391.12 $382.72 $430.56 $261.90 $294.64$347.66 $391.12 $382.72 $430.56 $261.90 $294.64$347.66 $391.12 $382.72 $430.56 $261.90 $294.64$349.05 $392.68 $384.25 $432.28 $262.95 $295.82$356.00 $400.50 $391.91 $440.89 $268.19 $301.71$364.35 $409.89 $401.09 $451.23 $274.47 $308.78$377.91 $425.14 $416.02 $468.02 $284.69 $320.27$389.03 $437.66 $428.26 $481.80 $293.07 $329.70$394.59 $463.65 $434.39 $510.40 $297.26 $349.28$402.94 $473.45 $443.57 $521.20 $303.54 $356.66$411.28 $483.26 $452.76 $531.99 $309.83 $364.05$416.50 $489.38 $458.50 $538.74 $313.76 $368.66$422.06 $495.92 $464.62 $545.93 $317.95 $373.59$424.84 $499.19 $467.68 $549.53 $320.04 $376.05$427.62 $502.46 $470.75 $553.13 $322.14 $378.51$430.40 $505.72 $473.81 $556.72 $324.23 $380.97$433.18 $508.99 $476.87 $560.32 $326.33 $383.43$438.75 $515.53 $482.99 $567.52 $330.52 $388.36$444.31 $544.28 $489.12 $599.17 $334.71 $410.02$452.65 $554.50 $498.30 $610.42 $340.99 $417.72$460.65 $564.30 $507.10 $621.20 $347.02 $425.10$471.77 $577.92 $519.35 $636.21 $355.40 $435.36$485.68 $594.96 $534.66 $654.96 $365.87 $448.20$502.02 $614.98 $552.65 $676.99 $378.18 $463.27$521.49 $638.83 $574.08 $703.25 $392.85 $481.24$543.39 $665.66 $598.19 $732.78 $409.35 $501.45$568.42 $696.32 $625.75 $766.54 $428.21 $524.55$593.11 $726.56 $652.92 $799.83 $446.80 $547.33$620.92 $853.77 $683.54 $939.86 $467.75 $643.16$648.39 $891.53 $713.77 $981.44 $488.44 $671.61$678.63 $933.12 $747.07 $1,027.22 $511.23 $702.94$709.23 $975.19 $780.75 $1,073.53 $534.28 $734.63$742.25 $1,020.60 $817.11 $1,123.52 $559.16 $768.84$775.28 $1,066.01 $853.47 $1,173.52 $584.04 $803.05$811.09 $1,115.25 $892.89 $1,227.72 $611.01 $840.14$847.25 $1,164.97 $932.69 $1,282.45 $638.25 $877.59$885.84 $1,218.03 $975.17 $1,340.86 $667.32 $917.57$904.96 $1,244.32 $996.22 $1,369.80 $681.73 $937.37$943.55 $1,297.38 $1,038.70 $1,428.22 $710.80 $977.35$976.92 $1,343.27 $1,075.44 $1,478.73 $735.94 $1,011.92$998.83 $1,373.39 $1,099.55 $1,511.89 $752.44 $1,034.60

$1,026.29 $1,411.15 $1,129.79 $1,553.46 $773.13 $1,063.05$1,042.98 $1,434.10 $1,148.16 $1,578.72 $785.70 $1,080.34

Yes Yes Yes

50%$5,200

Silver BronzePersonal Choice Network Personal Choice Network Personal Choice Network

8 8 816884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20

Personal Choice PPO Silver HSA-0 $2,100/70%Personal Choice PPO Silver HSA-0 $3,000/90% Personal Choice PPO Bronze HSA-0 $5,200/50%31609PA0150034 31609PA0150035 31609PA0150036

16884.WR-I Rev. 1.20

Silver









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$6,900 $3,4000% 0%

0% after ded 0% after ded$6,900 $6,900

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$215.73 $215.73 $328.45 $328.45 $327.63 $327.63$234.91 $234.91 $357.65 $357.65 $356.75 $356.75$242.24 $242.24 $368.81 $368.81 $367.88 $367.88$249.57 $249.57 $379.97 $379.97 $379.02 $379.02$257.47 $257.47 $392.00 $392.00 $391.01 $391.01$265.36 $265.36 $404.02 $404.02 $403.00 $403.00$273.54 $273.54 $416.47 $416.47 $415.42 $415.42$282.00 $317.25 $429.35 $483.02 $428.27 $481.80$282.00 $317.25 $429.35 $483.02 $428.27 $481.80$282.00 $317.25 $429.35 $483.02 $428.27 $481.80$282.00 $317.25 $429.35 $483.02 $428.27 $481.80$283.13 $318.52 $431.07 $484.95 $429.98 $483.73$288.77 $324.86 $439.65 $494.61 $438.55 $493.37$295.54 $332.48 $449.96 $506.20 $448.83 $504.93$306.53 $344.85 $466.70 $525.04 $465.53 $523.72$315.56 $355.00 $480.44 $540.50 $479.23 $539.14$320.07 $376.08 $487.31 $572.59 $486.09 $571.15$326.84 $384.03 $497.62 $584.70 $496.36 $583.23$333.61 $391.99 $507.92 $596.81 $506.64 $595.31$337.84 $396.96 $514.36 $604.37 $513.07 $602.85$342.35 $402.26 $521.23 $612.45 $519.92 $610.91$344.60 $404.91 $524.67 $616.48 $523.35 $614.93$346.86 $407.56 $528.10 $620.52 $526.77 $618.96$349.12 $410.21 $531.54 $624.55 $530.20 $622.98$351.37 $412.86 $534.97 $628.59 $533.62 $627.01$355.88 $418.16 $541.84 $636.66 $540.48 $635.06$360.40 $441.49 $548.71 $672.17 $547.33 $670.48$367.16 $449.78 $559.01 $684.79 $557.61 $683.07$373.65 $457.72 $568.89 $696.89 $567.46 $695.14$382.67 $468.78 $582.63 $713.72 $581.16 $711.92$393.95 $482.59 $599.80 $734.76 $598.29 $732.91$407.21 $498.83 $619.98 $759.48 $618.42 $757.57$423.00 $518.18 $644.03 $788.93 $642.41 $786.95$440.77 $539.94 $671.07 $822.07 $669.39 $820.00$461.07 $564.81 $701.99 $859.93 $700.22 $857.77$481.09 $589.34 $732.47 $897.28 $730.63 $895.02$503.65 $692.52 $766.82 $1,054.38 $764.89 $1,051.72$525.93 $723.15 $800.74 $1,101.01 $798.72 $1,098.24$550.46 $756.89 $838.09 $1,152.38 $835.98 $1,149.48$575.28 $791.01 $875.87 $1,204.33 $873.67 $1,201.30$602.07 $827.85 $916.66 $1,260.41 $914.36 $1,257.24$628.86 $864.68 $957.45 $1,316.49 $955.04 $1,313.18$657.91 $904.62 $1,001.67 $1,377.30 $999.15 $1,373.84$687.23 $944.95 $1,046.33 $1,438.70 $1,043.69 $1,435.08$718.54 $987.99 $1,093.98 $1,504.23 $1,091.23 $1,500.44$734.05 $1,009.31 $1,117.60 $1,536.70 $1,114.79 $1,532.83$765.35 $1,052.35 $1,165.26 $1,602.23 $1,162.32 $1,598.20$792.42 $1,089.58 $1,206.47 $1,658.90 $1,203.44 $1,654.73$810.19 $1,114.01 $1,233.52 $1,696.09 $1,230.42 $1,691.83$832.46 $1,144.64 $1,267.44 $1,742.73 $1,264.25 $1,738.35$846.00 $1,163.25 $1,288.05 $1,771.07 $1,284.81 $1,766.61

$5,000$40 no ded/$80 no ded

Yes Yes Yes

0%$2,500

Bronze Gold GoldPersonal Choice Network Personal Choice Network Personal Choice Network

8 8 816884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20

Personal Choice PPO Bronze HSA-0 $6,900/100%Personal Choice PPO Gold HRA-25 $3,400/100%Personal Choice PPO Gold Classic $2,500 $40/$80/100%31609PA0150037 31609PA0150039 31609PA0150047









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$231.01 $231.01 $237.50 $237.50 $294.65 $294.65$251.55 $251.55 $258.61 $258.61 $320.84 $320.84$259.40 $259.40 $266.69 $266.69 $330.85 $330.85$267.25 $267.25 $274.76 $274.76 $340.87 $340.87$275.71 $275.71 $283.45 $283.45 $351.65 $351.65$284.16 $284.16 $292.14 $292.14 $362.44 $362.44$292.92 $292.92 $301.15 $301.15 $373.61 $373.61$301.98 $339.73 $310.46 $349.27 $385.16 $433.31$301.98 $339.73 $310.46 $349.27 $385.16 $433.31$301.98 $339.73 $310.46 $349.27 $385.16 $433.31$301.98 $339.73 $310.46 $349.27 $385.16 $433.31$303.19 $341.09 $311.70 $350.66 $386.70 $435.04$309.23 $347.88 $317.91 $357.65 $394.40 $443.70$316.48 $356.03 $325.36 $366.03 $403.65 $454.10$328.25 $369.28 $337.47 $379.65 $418.67 $471.00$337.92 $380.16 $347.40 $390.83 $430.99 $484.87$342.75 $402.73 $352.37 $414.04 $437.16 $513.66$349.99 $411.24 $359.82 $422.79 $446.40 $524.52$357.24 $419.76 $367.27 $431.55 $455.64 $535.38$361.77 $425.08 $371.93 $437.02 $461.42 $542.17$366.60 $430.76 $376.90 $442.86 $467.58 $549.41$369.02 $433.60 $379.38 $445.77 $470.67 $553.03$371.44 $436.44 $381.87 $448.69 $473.75 $556.65$373.85 $439.28 $384.35 $451.61 $476.83 $560.27$376.27 $442.11 $386.83 $454.53 $479.91 $563.89$381.10 $447.79 $391.80 $460.37 $486.07 $571.13$385.93 $472.76 $396.77 $486.04 $492.23 $602.99$393.18 $481.64 $404.22 $495.17 $501.48 $614.31$400.12 $490.15 $411.36 $503.92 $510.34 $625.16$409.79 $501.99 $421.29 $516.09 $522.66 $640.26$421.87 $516.79 $433.71 $531.30 $538.07 $659.13$436.06 $534.17 $448.30 $549.17 $556.17 $681.31$452.97 $554.89 $465.69 $570.47 $577.74 $707.73$471.99 $578.19 $485.25 $594.43 $602.01 $737.46$493.74 $604.83 $507.60 $621.81 $629.74 $771.43$515.18 $631.09 $529.64 $648.81 $657.08 $804.93$539.34 $741.59 $554.48 $762.41 $687.90 $945.86$563.19 $774.39 $579.01 $796.14 $718.32 $987.69$589.46 $810.51 $606.02 $833.27 $751.83 $1,033.77$616.04 $847.05 $633.34 $870.84 $785.73 $1,080.37$644.73 $886.50 $662.83 $911.39 $822.32 $1,130.69$673.42 $925.95 $692.33 $951.95 $858.91 $1,181.00$704.52 $968.71 $724.30 $995.92 $898.58 $1,235.55$735.93 $1,011.90 $756.59 $1,040.31 $938.63 $1,290.62$769.45 $1,057.99 $791.05 $1,087.70 $981.39 $1,349.41$786.05 $1,080.82 $808.13 $1,111.18 $1,002.57 $1,378.54$819.57 $1,126.91 $842.59 $1,158.56 $1,045.32 $1,437.32$848.56 $1,166.78 $872.39 $1,199.54 $1,082.30 $1,488.16$867.59 $1,192.93 $891.95 $1,226.43 $1,106.56 $1,521.53$891.44 $1,225.74 $916.48 $1,260.16 $1,136.99 $1,563.36$905.94 $1,245.67 $931.38 $1,280.65 $1,155.48 $1,588.79

$8,150 $8,150 $6,900Yes Yes Yes

10% 0% 0%$50 no ded/$100 no ded $40 no ded/$80 no ded 0% after ded

Silver Silver Silver$5,000 $4,750 $3,500

8Personal Choice Network Personal Choice Network Personal Choice Network

16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.208 8

31609PA0150050Personal Choice PPO Silver Classic $5,000/$50/$100/90%Personal Choice PPO Silver Secure $4,750/$40/$80/$600Personal Choice PPO Silver HSA-0 $3,500/100%

31609PA0150048 31609PA0150049









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco$245.76 $245.76$267.60 $267.60$275.95 $275.95$284.31 $284.31$293.30 $293.30$302.30 $302.30$311.61 $311.61$321.25 $361.41$321.25 $361.41$321.25 $361.41$321.25 $361.41$322.54 $362.85$328.96 $370.08$336.67 $378.75$349.20 $392.85$359.48 $404.41$364.62 $428.43$372.33 $437.49$380.04 $446.55$384.86 $452.21$390.00 $458.25$392.57 $461.27$395.14 $464.29$397.71 $467.31$400.28 $470.33$405.42 $476.37$410.56 $502.93$418.27 $512.38$425.66 $521.43$435.94 $534.02$448.79 $549.76$463.89 $568.26$481.88 $590.30$502.11 $615.09$525.24 $643.42$548.05 $671.36$573.75 $788.91$599.13 $823.81$627.08 $862.24$655.35 $901.11$685.87 $943.07$716.39 $985.03$749.48 $1,030.53$782.89 $1,076.47$818.55 $1,125.50$836.21 $1,149.79$871.87 $1,198.82$902.71 $1,241.23$922.95 $1,269.06$948.33 $1,303.95$963.75 $1,325.16

$6,900Yes

20%20% after ded/20% after ded

Silver$3,000


16884.WR-I Rev. 1.20

31609PA0170001Personal Choice EPO Silver HSA-0 $3,000/80%

HIOS Plan ID Plan Marketing Name Product MetalOn/Off

Exchange Network Rating Area Counties Covered

31609PA0150025 Personal Choice PPO Platinum Preferred $10/$20/$200 PPO Platinum Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150026 Personal Choice PPO Platinum Preferred $20/$40/$250 PPO Platinum Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150027 Personal Choice PPO Gold Preferred $40/$80/$600 PPO Gold Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150028 Personal Choice PPO Gold Classic $1,500/$20/$40/80% PPO Gold Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150029 Personal Choice PPO Silver Classic $3,750/$30/$60/70% PPO Silver Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150030 Personal Choice PPO Platinum HSA-50 $1,800/100% PPO Platinum Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150031 Personal Choice PPO Gold HSA-25 $2,400/$25/$50/90% PPO Gold Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150032 Personal Choice PPO Gold HSA-0 $2,100/100% PPO Gold Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150033 Personal Choice PPO Gold HSA-25 $2,600/80% PPO Gold Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150034 Personal Choice PPO Silver HSA-0 $2,100/70% PPO Silver Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150035 Personal Choice PPO Silver HSA-0 $3,000/90% PPO Silver Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150036 Personal Choice PPO Bronze HSA-0 $5,200/50% PPO Bronze Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150037 Personal Choice PPO Bronze HSA-0 $6,900/100% PPO Bronze Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150039 Personal Choice PPO Gold HRA-25 $3,400/100% PPO Gold Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150047 Personal Choice PPO Gold Classic $2,500 $40/$80/100% PPO Gold Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150048 Personal Choice PPO Silver Classic $5,000/$50/$100/90% PPO Silver Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150049 Personal Choice PPO Silver Secure $4,750/$40/$80/$600 PPO Silver Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia31609PA0150050 Personal Choice PPO Silver HSA-0 $3,500/100% PPO Silver Off PPO 8 Bucks, Chester, Delaware, Montgomery, Philadelphia


Plan Design Summary

Company Name QCC Insurance Company, Inc.Market Small GroupRATES FOR AGE 21, NON-TOBACCO USER, BY RATING AREA AND COUNTY

RATING AREA 812,705 14,784 10,778 22,091 11,234


Exchange Bucks Chester Delaware Montgomery Philadelphia

31609PA0150025 Personal Choice PPO Platinum Preferred $10/$20/$200 PPO Platinum Off $574.27 $574.27 $574.27 $574.27 $574.2731609PA0150026 Personal Choice PPO Platinum Preferred $20/$40/$250 PPO Platinum Off $546.62 $546.62 $546.62 $546.62 $546.6231609PA0150027 Personal Choice PPO Gold Preferred $40/$80/$600 PPO Gold Off $436.60 $436.60 $436.60 $436.60 $436.6031609PA0150028 Personal Choice PPO Gold Classic $1,500/$20/$40/80% PPO Gold Off $428.67 $428.67 $428.67 $428.67 $428.6731609PA0150029 Personal Choice PPO Silver Classic $3,750/$30/$60/70% PPO Silver Off $350.25 $350.25 $350.25 $350.25 $350.2531609PA0150030 Personal Choice PPO Platinum HSA-50 $1,800/100% PPO Platinum Off $487.54 $487.54 $487.54 $487.54 $487.5431609PA0150031 Personal Choice PPO Gold HSA-25 $2,400/$25/$50/90% PPO Gold Off $406.49 $406.49 $406.49 $406.49 $406.4931609PA0150032 Personal Choice PPO Gold HSA-0 $2,100/100% PPO Gold Off $472.85 $472.85 $472.85 $472.85 $472.8531609PA0150033 Personal Choice PPO Gold HSA-25 $2,600/80% PPO Gold Off $369.13 $369.13 $369.13 $369.13 $369.1331609PA0150034 Personal Choice PPO Silver HSA-0 $2,100/70% PPO Silver Off $347.66 $347.66 $347.66 $347.66 $347.6631609PA0150035 Personal Choice PPO Silver HSA-0 $3,000/90% PPO Silver Off $382.72 $382.72 $382.72 $382.72 $382.7231609PA0150036 Personal Choice PPO Bronze HSA-0 $5,200/50% PPO Bronze Off $261.90 $261.90 $261.90 $261.90 $261.9031609PA0150037 Personal Choice PPO Bronze HSA-0 $6,900/100% PPO Bronze Off $282.00 $282.00 $282.00 $282.00 $282.0031609PA0150039 Personal Choice PPO Gold HRA-25 $3,400/100% PPO Gold Off $429.35 $429.35 $429.35 $429.35 $429.3531609PA0150047 Personal Choice PPO Gold Classic $2,500 $40/$80/100% PPO Gold Off $428.27 $428.27 $428.27 $428.27 $428.2731609PA0150048 Personal Choice PPO Silver Classic $5,000/$50/$100/90% PPO Silver Off $301.98 $301.98 $301.98 $301.98 $301.9831609PA0150049 Personal Choice PPO Silver Secure $4,750/$40/$80/$600 PPO Silver Off $310.46 $310.46 $310.46 $310.46 $310.4631609PA0150050 Personal Choice PPO Silver HSA-0 $3,500/100% PPO Silver Off $385.16 $385.16 $385.16 $385.16 $385.1631609PA0170001 Personal Choice EPO Silver HSA-0 $3,000/80% EPO Silver Off $321.25 $321.25 $321.25 $321.25 $321.25

02-01-2019 Number of Covered Lives by Rating County

RATE PAGES









Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco0-14 $445.97 $445.97 $424.51 $424.51 $339.06 $339.0615 $485.61 $485.61 $462.24 $462.24 $369.19 $369.1916 $500.77 $500.77 $476.67 $476.67 $380.72 $380.7217 $515.93 $515.93 $491.10 $491.10 $392.24 $392.2418 $532.25 $532.25 $506.63 $506.63 $404.65 $404.6519 $548.57 $548.57 $522.17 $522.17 $417.06 $417.0620 $565.48 $565.48 $538.26 $538.26 $429.91 $429.9121 $582.97 $655.84 $554.91 $624.27 $443.21 $498.6122 $582.97 $655.84 $554.91 $624.27 $443.21 $498.6123 $582.97 $655.84 $554.91 $624.27 $443.21 $498.6124 $582.97 $655.84 $554.91 $624.27 $443.21 $498.6125 $585.30 $658.46 $557.13 $626.77 $444.98 $500.6126 $596.96 $671.58 $568.23 $639.26 $453.85 $510.5827 $610.95 $687.32 $581.55 $654.24 $464.48 $522.5428 $633.69 $712.90 $603.19 $678.59 $481.77 $541.9929 $652.34 $733.89 $620.94 $698.56 $495.95 $557.9530 $661.67 $777.46 $629.82 $740.04 $503.04 $591.0831 $675.66 $793.90 $643.14 $755.69 $513.68 $603.5732 $689.65 $810.34 $656.46 $771.34 $524.32 $616.0733 $698.40 $820.62 $664.78 $781.12 $530.97 $623.8834 $707.73 $831.58 $673.66 $791.55 $538.06 $632.2235 $712.39 $837.06 $678.10 $796.77 $541.60 $636.3836 $717.05 $842.54 $682.54 $801.98 $545.15 $640.5537 $721.72 $848.02 $686.98 $807.20 $548.69 $644.7238 $726.38 $853.50 $691.42 $812.42 $552.24 $648.8839 $735.71 $864.46 $700.30 $822.85 $559.33 $657.2140 $745.04 $912.67 $709.17 $868.74 $566.42 $693.8741 $759.03 $929.81 $722.49 $885.05 $577.06 $706.9042 $772.44 $946.23 $735.26 $900.69 $587.25 $719.3943 $791.09 $969.09 $753.01 $922.44 $601.44 $736.7644 $814.41 $997.65 $775.21 $949.63 $619.16 $758.4845 $841.81 $1,031.22 $801.29 $981.58 $640.00 $783.9946 $874.46 $1,071.21 $832.37 $1,019.65 $664.82 $814.4047 $911.18 $1,116.20 $867.32 $1,062.47 $692.74 $848.6048 $953.16 $1,167.62 $907.28 $1,111.42 $724.65 $887.6949 $994.55 $1,218.32 $946.68 $1,159.68 $756.12 $926.2450 $1,041.18 $1,431.63 $991.07 $1,362.72 $791.57 $1,088.4151 $1,087.24 $1,494.95 $1,034.91 $1,423.00 $826.59 $1,136.5652 $1,137.96 $1,564.69 $1,083.18 $1,489.38 $865.15 $1,189.5853 $1,189.26 $1,635.23 $1,132.02 $1,556.52 $904.15 $1,243.2054 $1,244.64 $1,711.38 $1,184.73 $1,629.01 $946.25 $1,301.1055 $1,300.02 $1,787.53 $1,237.45 $1,701.49 $988.36 $1,358.9956 $1,360.07 $1,870.09 $1,294.61 $1,780.08 $1,034.01 $1,421.7657 $1,420.70 $1,953.46 $1,352.32 $1,859.43 $1,080.10 $1,485.1458 $1,485.41 $2,042.44 $1,413.91 $1,944.13 $1,129.30 $1,552.7959 $1,517.47 $2,086.52 $1,444.43 $1,986.09 $1,153.68 $1,586.3060 $1,582.18 $2,175.50 $1,506.03 $2,070.79 $1,202.87 $1,653.9561 $1,638.15 $2,252.45 $1,559.30 $2,144.03 $1,245.42 $1,712.4562 $1,674.87 $2,302.95 $1,594.26 $2,192.10 $1,273.34 $1,750.8563 $1,720.93 $2,366.28 $1,638.09 $2,252.38 $1,308.36 $1,798.99

64+ $1,748.91 $2,404.75 $1,664.73 $2,289.00 $1,329.63 $1,828.24

31609PA0150026 31609PA0150027


16884.WR-I Rev. 1.2016884.WR-I Rev. 1.20


88

YesYes

Personal Choice PPO Gold Preferred $40/$80/$600Personal Choice PPO Platinum Preferred $20/$40/$250


PPOApril 1, 2020

Yes



8

31609PA0150025

16884.WR-I Rev. 1.20

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$3,750 $1,80030% 0%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$332.91 $332.91 $272.00 $272.00 $378.62 $378.62$362.50 $362.50 $296.18 $296.18 $412.28 $412.28$373.81 $373.81 $305.43 $305.43 $425.14 $425.14$385.13 $385.13 $314.67 $314.67 $438.01 $438.01$397.31 $397.31 $324.63 $324.63 $451.87 $451.87$409.49 $409.49 $334.58 $334.58 $465.73 $465.73$422.11 $422.11 $344.89 $344.89 $480.08 $480.08$435.17 $489.57 $355.56 $400.01 $494.93 $556.80$435.17 $489.57 $355.56 $400.01 $494.93 $556.80$435.17 $489.57 $355.56 $400.01 $494.93 $556.80$435.17 $489.57 $355.56 $400.01 $494.93 $556.80$436.91 $491.52 $356.98 $401.61 $496.91 $559.02$445.61 $501.32 $364.09 $409.61 $506.81 $570.16$456.06 $513.07 $372.63 $419.21 $518.69 $583.52$473.03 $532.16 $386.49 $434.81 $537.99 $605.24$486.96 $547.82 $397.87 $447.61 $553.83 $623.06$493.92 $580.35 $403.56 $474.18 $561.75 $660.05$504.36 $592.63 $412.09 $484.21 $573.62 $674.01$514.81 $604.90 $420.63 $494.24 $585.50 $687.97$521.33 $612.57 $425.96 $500.50 $592.93 $696.69$528.30 $620.75 $431.65 $507.19 $600.85 $705.99$531.78 $624.84 $434.49 $510.53 $604.80 $710.65$535.26 $628.93 $437.34 $513.87 $608.76 $715.30$538.74 $633.02 $440.18 $517.22 $612.72 $719.95$542.22 $637.11 $443.03 $520.56 $616.68 $724.60$549.18 $645.29 $448.72 $527.24 $624.60 $733.91$556.15 $681.28 $454.41 $556.65 $632.52 $774.84$566.59 $694.07 $462.94 $567.10 $644.40 $789.39$576.60 $706.34 $471.12 $577.12 $655.78 $803.33$590.53 $723.39 $482.49 $591.06 $671.62 $822.73$607.93 $744.72 $496.72 $608.48 $691.42 $846.99$628.39 $769.77 $513.43 $628.95 $714.68 $875.48$652.76 $799.62 $533.34 $653.34 $742.40 $909.43$680.17 $833.21 $555.74 $680.78 $773.58 $947.63$711.50 $871.59 $581.34 $712.14 $809.21 $991.28$742.40 $909.44 $606.59 $743.07 $844.35 $1,034.33$777.21 $1,068.67 $635.03 $873.17 $883.94 $1,215.42$811.59 $1,115.94 $663.12 $911.79 $923.04 $1,269.19$849.45 $1,168.00 $694.05 $954.32 $966.10 $1,328.39$887.75 $1,220.65 $725.34 $997.35 $1,009.66 $1,388.28$929.09 $1,277.50 $759.12 $1,043.79 $1,056.68 $1,452.93$970.43 $1,334.34 $792.90 $1,090.24 $1,103.69 $1,517.58

$1,015.25 $1,395.97 $829.52 $1,140.59 $1,154.67 $1,587.67$1,060.51 $1,458.20 $866.50 $1,191.44 $1,206.14 $1,658.45$1,108.81 $1,524.62 $905.97 $1,245.70 $1,261.08 $1,733.99$1,132.75 $1,557.53 $925.52 $1,272.59 $1,288.30 $1,771.42$1,181.05 $1,623.95 $964.99 $1,326.86 $1,343.24 $1,846.96$1,222.83 $1,681.39 $999.12 $1,373.79 $1,390.75 $1,912.29$1,250.24 $1,719.08 $1,021.52 $1,404.60 $1,421.93 $1,955.16$1,284.62 $1,766.36 $1,049.61 $1,443.22 $1,461.03 $2,008.92$1,305.51 $1,795.08 $1,066.68 $1,466.69 $1,484.79 $2,041.59

0% after ded

Yes

Personal Choice Network8

16884.WR-I Rev. 1.20Personal Choice PPO Platinum HSA-50 $1,800/100%

31609PA0150030

Yes

16884.WR-I Rev. 1.208

31609PA0150028

$6,500


$1,50020%


Platinum

June 30, 2020

$8,150Yes



Silver

31609PA0150029

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$2,400 $2,10010% 0%

$25/$50 20% after ded$6,900 $6,900 $6,900

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$315.68 $315.68 $367.21 $367.21 $286.66 $286.66$343.74 $343.74 $399.85 $399.85 $312.14 $312.14$354.47 $354.47 $412.33 $412.33 $321.88 $321.88$365.20 $365.20 $424.81 $424.81 $331.63 $331.63$376.75 $376.75 $438.25 $438.25 $342.12 $342.12$388.30 $388.30 $451.69 $451.69 $352.61 $352.61$400.27 $400.27 $465.61 $465.61 $363.48 $363.48$412.65 $464.23 $480.01 $540.01 $374.72 $421.56$412.65 $464.23 $480.01 $540.01 $374.72 $421.56$412.65 $464.23 $480.01 $540.01 $374.72 $421.56$412.65 $464.23 $480.01 $540.01 $374.72 $421.56$414.30 $466.09 $481.93 $542.17 $376.22 $423.25$422.55 $475.37 $491.53 $552.97 $383.71 $431.68$432.46 $486.51 $503.05 $565.93 $392.71 $441.79$448.55 $504.62 $521.77 $586.99 $407.32 $458.24$461.76 $519.47 $537.13 $604.27 $419.31 $471.73$468.36 $550.32 $544.81 $640.15 $425.31 $499.74$478.26 $561.96 $556.33 $653.69 $434.30 $510.30$488.16 $573.59 $567.85 $667.23 $443.29 $520.87$494.35 $580.87 $575.05 $675.69 $448.91 $527.47$500.96 $588.62 $582.73 $684.71 $454.91 $534.52$504.26 $592.50 $586.57 $689.22 $457.91 $538.04$507.56 $596.38 $590.41 $693.73 $460.91 $541.56$510.86 $600.26 $594.25 $698.25 $463.90 $545.09$514.16 $604.14 $598.09 $702.76 $466.90 $548.61$520.76 $611.90 $605.77 $711.78 $472.90 $555.65$527.37 $646.02 $613.45 $751.48 $478.89 $586.64$537.27 $658.16 $624.97 $765.59 $487.89 $597.66$546.76 $669.78 $636.01 $779.12 $496.50 $608.22$559.97 $685.96 $651.37 $797.93 $508.50 $622.91$576.47 $706.18 $670.57 $821.45 $523.48 $641.27$595.87 $729.94 $693.13 $849.09 $541.10 $662.84$618.98 $758.24 $720.02 $882.02 $562.08 $688.55$644.97 $790.09 $750.26 $919.06 $585.69 $717.47$674.68 $826.49 $784.82 $961.40 $612.67 $750.52$703.98 $862.38 $818.90 $1,003.15 $639.27 $783.11$736.99 $1,013.37 $857.30 $1,178.78 $669.25 $920.22$769.59 $1,058.19 $895.22 $1,230.93 $698.85 $960.92$805.49 $1,107.55 $936.98 $1,288.35 $731.45 $1,005.75$841.81 $1,157.48 $979.22 $1,346.43 $764.43 $1,051.09$881.01 $1,211.39 $1,024.82 $1,409.13 $800.03 $1,100.04$920.21 $1,265.29 $1,070.42 $1,471.83 $835.63 $1,148.99$962.71 $1,323.73 $1,119.86 $1,539.81 $874.22 $1,202.05

$1,005.63 $1,382.74 $1,169.78 $1,608.45 $913.19 $1,255.64$1,051.43 $1,445.72 $1,223.07 $1,681.72 $954.79 $1,312.83$1,074.13 $1,476.93 $1,249.47 $1,718.02 $975.40 $1,341.17$1,119.93 $1,539.91 $1,302.75 $1,791.28 $1,016.99 $1,398.36$1,159.55 $1,594.38 $1,348.83 $1,854.64 $1,052.96 $1,447.82$1,185.54 $1,630.12 $1,379.07 $1,896.22 $1,076.57 $1,480.28$1,218.14 $1,674.95 $1,416.99 $1,948.36 $1,106.17 $1,520.99$1,237.95 $1,702.18 $1,440.03 $1,980.04 $1,124.16 $1,545.72

0% after ded

Yes Yes Yes

20%$2,600

Personal Choice Network Personal Choice Network Personal Choice Network8 8 8

16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20Personal Choice PPO Gold HSA-25 $2,400/$25/$50/90%Personal Choice PPO Gold HSA-0 $2,100/100%Personal Choice PPO Gold HSA-25 $2,600/80%

31609PA0150031 31609PA0150032 31609PA0150033

16884.WR-I Rev. 1.20

Gold Gold Gold

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$2,100 $3,00030% 10%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$269.99 $269.99 $297.22 $297.22 $203.39 $203.39$293.99 $293.99 $323.64 $323.64 $221.47 $221.47$303.17 $303.17 $333.74 $333.74 $228.38 $228.38$312.34 $312.34 $343.84 $343.84 $235.29 $235.29$322.23 $322.23 $354.72 $354.72 $242.74 $242.74$332.11 $332.11 $365.60 $365.60 $250.18 $250.18$342.34 $342.34 $376.86 $376.86 $257.89 $257.89$352.93 $397.05 $388.52 $437.09 $265.87 $299.10$352.93 $397.05 $388.52 $437.09 $265.87 $299.10$352.93 $397.05 $388.52 $437.09 $265.87 $299.10$352.93 $397.05 $388.52 $437.09 $265.87 $299.10$354.34 $398.63 $390.07 $438.83 $266.93 $300.30$361.40 $406.58 $397.84 $447.58 $272.25 $306.28$369.87 $416.10 $407.17 $458.07 $278.63 $313.46$383.63 $431.59 $422.32 $475.11 $289.00 $325.13$394.93 $444.29 $434.75 $489.10 $297.51 $334.70$400.58 $470.68 $440.97 $518.14 $301.76 $354.57$409.05 $480.63 $450.29 $529.10 $308.14 $362.07$417.52 $490.58 $459.62 $540.05 $314.52 $369.57$422.81 $496.80 $465.45 $546.90 $318.51 $374.25$428.46 $503.44 $471.66 $554.20 $322.77 $379.25$431.28 $506.75 $474.77 $557.86 $324.89 $381.75$434.10 $510.07 $477.88 $561.51 $327.02 $384.25$436.93 $513.39 $480.99 $565.16 $329.15 $386.75$439.75 $516.71 $484.10 $568.81 $331.27 $389.25$445.40 $523.34 $490.31 $576.12 $335.53 $394.25$451.04 $552.53 $496.53 $608.25 $339.78 $416.23$459.51 $562.91 $505.85 $619.67 $346.16 $424.05$467.63 $572.85 $514.79 $630.62 $352.28 $431.54$478.93 $586.68 $527.22 $645.85 $360.79 $441.96$493.04 $603.98 $542.76 $664.88 $371.42 $454.99$509.63 $624.30 $561.02 $687.25 $383.92 $470.30$529.40 $648.51 $582.78 $713.91 $398.81 $488.54$551.63 $675.75 $607.26 $743.89 $415.55 $509.05$577.04 $706.87 $635.23 $778.16 $434.70 $532.50$602.10 $737.57 $662.82 $811.95 $453.57 $555.63$630.33 $866.71 $693.90 $954.11 $474.84 $652.91$658.21 $905.04 $724.59 $996.31 $495.85 $681.79$688.92 $947.26 $758.39 $1,042.79 $518.98 $713.60$719.98 $989.97 $792.58 $1,089.80 $542.37 $745.77$753.51 $1,036.07 $829.49 $1,140.55 $567.63 $780.49$787.03 $1,082.17 $866.40 $1,191.30 $592.89 $815.22$823.39 $1,132.16 $906.42 $1,246.32 $620.27 $852.88$860.09 $1,182.62 $946.82 $1,301.88 $647.93 $890.90$899.27 $1,236.49 $989.95 $1,361.18 $677.44 $931.48$918.68 $1,263.18 $1,011.32 $1,390.56 $692.06 $951.58$957.85 $1,317.05 $1,054.44 $1,449.86 $721.57 $992.16$991.73 $1,363.63 $1,091.74 $1,501.14 $747.09 $1,027.26

$1,013.97 $1,394.21 $1,116.22 $1,534.80 $763.84 $1,050.29$1,041.85 $1,432.54 $1,146.91 $1,577.00 $784.85 $1,079.17$1,058.79 $1,455.84 $1,165.56 $1,602.65 $797.61 $1,096.71

Yes Yes Yes

50%$5,200

Silver BronzePersonal Choice Network Personal Choice Network Personal Choice Network

8 8 816884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20

Personal Choice PPO Silver HSA-0 $2,100/70%Personal Choice PPO Silver HSA-0 $3,000/90% Personal Choice PPO Bronze HSA-0 $5,200/50%31609PA0150034 31609PA0150035 31609PA0150036

16884.WR-I Rev. 1.20

Silver

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$6,900 $3,4000% 0%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$219.00 $219.00 $333.43 $333.43 $332.59 $332.59$238.46 $238.46 $363.07 $363.07 $362.16 $362.16$245.91 $245.91 $374.40 $374.40 $373.46 $373.46$253.35 $253.35 $385.74 $385.74 $384.76 $384.76$261.36 $261.36 $397.94 $397.94 $396.94 $396.94$269.38 $269.38 $410.14 $410.14 $409.11 $409.11$277.68 $277.68 $422.78 $422.78 $421.72 $421.72$286.27 $322.05 $435.86 $490.34 $434.76 $489.11$286.27 $322.05 $435.86 $490.34 $434.76 $489.11$286.27 $322.05 $435.86 $490.34 $434.76 $489.11$286.27 $322.05 $435.86 $490.34 $434.76 $489.11$287.42 $323.34 $437.60 $492.30 $436.50 $491.06$293.14 $329.78 $446.32 $502.11 $445.19 $500.84$300.01 $337.51 $456.78 $513.88 $455.63 $512.58$311.18 $350.07 $473.78 $533.00 $472.58 $531.66$320.34 $360.38 $487.73 $548.69 $486.50 $547.31$324.92 $381.78 $494.70 $581.27 $493.45 $579.81$331.79 $389.85 $505.16 $593.57 $503.89 $592.07$338.66 $397.92 $515.62 $605.86 $514.32 $604.33$342.95 $402.97 $522.16 $613.54 $520.84 $611.99$347.53 $408.35 $529.13 $621.73 $527.80 $620.16$349.82 $411.04 $532.62 $625.83 $531.28 $624.25$352.11 $413.73 $536.11 $629.93 $534.75 $628.34$354.40 $416.42 $539.59 $634.02 $538.23 $632.42$356.69 $419.11 $543.08 $638.12 $541.71 $636.51$361.27 $424.50 $550.06 $646.32 $548.67 $644.68$365.85 $448.17 $557.03 $682.36 $555.62 $680.64$372.72 $456.59 $567.49 $695.17 $566.06 $693.42$379.31 $464.65 $577.51 $707.46 $576.06 $705.67$388.47 $475.87 $591.46 $724.54 $589.97 $722.71$399.92 $489.90 $608.90 $745.90 $607.36 $744.02$413.37 $506.38 $629.38 $770.99 $627.79 $769.05$429.41 $526.02 $653.79 $800.89 $652.14 $798.87$447.44 $548.11 $681.25 $834.53 $679.53 $832.42$468.05 $573.36 $712.63 $872.97 $710.83 $870.77$488.38 $598.26 $743.58 $910.88 $741.70 $908.58$511.28 $703.01 $778.45 $1,070.36 $776.48 $1,067.66$533.89 $734.10 $812.88 $1,117.71 $810.83 $1,114.89$558.80 $768.35 $850.80 $1,169.85 $848.65 $1,166.90$583.99 $802.99 $889.15 $1,222.59 $886.91 $1,219.50$611.19 $840.38 $930.56 $1,279.52 $928.21 $1,276.29$638.38 $877.78 $971.97 $1,336.46 $969.51 $1,333.08$667.87 $918.32 $1,016.86 $1,398.18 $1,014.30 $1,394.66$697.64 $959.25 $1,062.19 $1,460.51 $1,059.51 $1,456.83$729.42 $1,002.95 $1,110.57 $1,527.04 $1,107.77 $1,523.18$745.16 $1,024.60 $1,134.54 $1,560.00 $1,131.68 $1,556.06$776.94 $1,068.29 $1,182.92 $1,626.52 $1,179.94 $1,622.42$804.42 $1,106.08 $1,224.77 $1,684.05 $1,221.68 $1,679.80$822.45 $1,130.87 $1,252.23 $1,721.81 $1,249.07 $1,717.47$845.07 $1,161.97 $1,286.66 $1,769.16 $1,283.41 $1,764.69$858.81 $1,180.86 $1,307.58 $1,797.92 $1,304.28 $1,793.39

$5,000$40 no ded/$80 no ded

Yes Yes Yes

0%$2,500

Bronze Gold GoldPersonal Choice Network Personal Choice Network Personal Choice Network


Personal Choice PPO Bronze HSA-0 $6,900/100%Personal Choice PPO Gold HRA-25 $3,400/100%Personal Choice PPO Gold Classic $2,500 $40/$80/100%31609PA0150037 31609PA0150039 31609PA0150047

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$234.51 $234.51 $241.10 $241.10 $299.12 $299.12$255.36 $255.36 $262.53 $262.53 $325.70 $325.70$263.33 $263.33 $270.72 $270.72 $335.87 $335.87$271.30 $271.30 $278.92 $278.92 $346.04 $346.04$279.88 $279.88 $287.74 $287.74 $356.98 $356.98$288.46 $288.46 $296.57 $296.57 $367.93 $367.93$297.35 $297.35 $305.71 $305.71 $379.27 $379.27$306.55 $344.87 $315.16 $354.56 $391.00 $439.88$306.55 $344.87 $315.16 $354.56 $391.00 $439.88$306.55 $344.87 $315.16 $354.56 $391.00 $439.88$306.55 $344.87 $315.16 $354.56 $391.00 $439.88$307.78 $346.25 $316.42 $355.97 $392.56 $441.63$313.91 $353.15 $322.72 $363.06 $400.38 $450.43$321.26 $361.42 $330.29 $371.57 $409.77 $460.99$333.22 $374.87 $342.58 $385.40 $425.02 $478.14$343.03 $385.91 $352.66 $396.75 $437.53 $492.22$347.93 $408.82 $357.71 $420.31 $443.79 $521.45$355.29 $417.47 $365.27 $429.19 $453.17 $532.47$362.65 $426.11 $372.83 $438.08 $462.55 $543.50$367.25 $431.52 $377.56 $443.63 $468.42 $550.39$372.15 $437.28 $382.60 $449.56 $474.67 $557.74$374.60 $440.16 $385.13 $452.52 $477.80 $561.42$377.06 $443.04 $387.65 $455.48 $480.93 $565.09$379.51 $445.92 $390.17 $458.45 $484.06 $568.77$381.96 $448.80 $392.69 $461.41 $487.19 $572.44$386.87 $454.57 $397.73 $467.34 $493.44 $579.79$391.77 $479.92 $402.77 $493.40 $499.70 $612.13$399.13 $488.93 $410.34 $502.66 $509.08 $623.63$406.18 $497.57 $417.59 $511.54 $518.08 $634.64$415.99 $509.59 $427.67 $523.90 $530.59 $649.97$428.25 $524.61 $440.28 $539.34 $546.23 $669.13$442.66 $542.26 $455.09 $557.49 $564.60 $691.64$459.83 $563.29 $472.74 $579.11 $586.50 $718.46$479.14 $586.94 $492.60 $603.43 $611.13 $748.64$501.21 $613.98 $515.29 $631.23 $639.29 $783.12$522.97 $640.64 $537.66 $658.64 $667.05 $817.13$547.50 $752.81 $562.88 $773.95 $698.33 $960.20$571.72 $786.11 $587.77 $808.19 $729.22 $1,002.67$598.39 $822.78 $615.19 $845.89 $763.23 $1,049.44$625.36 $859.87 $642.93 $884.02 $797.64 $1,096.76$654.48 $899.92 $672.87 $925.19 $834.79 $1,147.83$683.61 $939.96 $702.81 $966.36 $871.93 $1,198.90$715.18 $983.37 $735.27 $1,010.99 $912.20 $1,254.28$747.06 $1,027.21 $768.04 $1,056.06 $952.87 $1,310.19$781.09 $1,074.00 $803.03 $1,104.16 $996.27 $1,369.87$797.95 $1,097.18 $820.36 $1,128.00 $1,017.77 $1,399.44$831.98 $1,143.97 $855.34 $1,176.10 $1,061.17 $1,459.11$861.41 $1,184.43 $885.60 $1,217.70 $1,098.71 $1,510.73$880.72 $1,210.99 $905.45 $1,245.00 $1,123.34 $1,544.60$904.94 $1,244.29 $930.35 $1,279.23 $1,154.23 $1,587.07$919.65 $1,264.52 $945.48 $1,300.04 $1,173.00 $1,612.88

$8,150 $8,150 $6,900Yes Yes Yes

10% 0% 0%$50 no ded/$100 no ded $40 no ded/$80 no ded 0% after ded

Silver Silver Silver$5,000 $4,750 $3,500

8Personal Choice Network Personal Choice Network Personal Choice Network

16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.208 8

31609PA0150050Personal Choice PPO Silver Classic $5,000/$50/$100/90%Personal Choice PPO Silver Secure $4,750/$40/$80/$600Personal Choice PPO Silver HSA-0 $3,500/100%

31609PA0150048 31609PA0150049

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco$249.48 $249.48$271.66 $271.66$280.14 $280.14$288.62 $288.62$297.75 $297.75$306.88 $306.88$316.34 $316.34$326.12 $366.89$326.12 $366.89$326.12 $366.89$326.12 $366.89$327.42 $368.35$333.95 $375.69$341.77 $384.50$354.49 $398.80$364.93 $410.54$370.15 $434.92$377.97 $444.12$385.80 $453.31$390.69 $459.06$395.91 $465.19$398.52 $468.26$401.13 $471.32$403.74 $474.39$406.35 $477.46$411.56 $483.59$416.78 $510.56$424.61 $520.15$432.11 $529.33$442.54 $542.12$455.59 $558.10$470.92 $576.87$489.18 $599.25$509.73 $624.41$533.21 $653.18$556.36 $681.54$582.45 $800.87$608.21 $836.29$636.59 $875.31$665.28 $914.77$696.27 $957.37$727.25 $999.97$760.84 $1,046.15$794.75 $1,092.79$830.95 $1,142.56$848.89 $1,167.22$885.09 $1,217.00$916.40 $1,260.05$936.94 $1,288.30$962.71 $1,323.72$978.36 $1,345.25

$6,900Yes

20%20% after ded/20% after ded

Silver$3,000


16884.WR-I Rev. 1.20


RATE PAGES





Plan Design Summary

RATE PAGES


RATING AREA 812,705 14,784 10,778 22,091 11,234





RATE PAGES









Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco0-14 $452.73 $452.73 $430.94 $430.94 $344.20 $344.2015 $492.97 $492.97 $469.25 $469.25 $374.79 $374.7916 $508.36 $508.36 $483.89 $483.89 $386.49 $386.4917 $523.74 $523.74 $498.54 $498.54 $398.19 $398.1918 $540.31 $540.31 $514.31 $514.31 $410.79 $410.7919 $556.88 $556.88 $530.08 $530.08 $423.38 $423.3820 $574.05 $574.05 $546.42 $546.42 $436.43 $436.4321 $591.80 $665.78 $563.32 $633.74 $449.93 $506.1722 $591.80 $665.78 $563.32 $633.74 $449.93 $506.1723 $591.80 $665.78 $563.32 $633.74 $449.93 $506.1724 $591.80 $665.78 $563.32 $633.74 $449.93 $506.1725 $594.17 $668.44 $565.57 $636.27 $451.73 $508.2026 $606.00 $681.75 $576.84 $648.94 $460.73 $518.3227 $620.21 $697.73 $590.36 $664.15 $471.53 $530.4728 $643.29 $723.70 $612.33 $688.87 $489.07 $550.2129 $662.22 $745.00 $630.36 $709.15 $503.47 $566.4130 $671.69 $789.24 $639.37 $751.26 $510.67 $600.0431 $685.90 $805.93 $652.89 $767.14 $521.47 $612.7332 $700.10 $822.62 $666.41 $783.03 $532.27 $625.4133 $708.98 $833.05 $674.86 $792.96 $539.02 $633.3434 $718.45 $844.17 $683.87 $803.55 $546.22 $641.8035 $723.18 $849.74 $688.38 $808.84 $549.81 $646.0336 $727.91 $855.30 $692.88 $814.14 $553.41 $650.2637 $732.65 $860.86 $697.39 $819.43 $557.01 $654.4938 $737.38 $866.42 $701.90 $824.73 $560.61 $658.7239 $746.85 $877.55 $710.91 $835.32 $567.81 $667.1840 $756.32 $926.49 $719.92 $881.91 $575.01 $704.3941 $770.52 $943.89 $733.44 $898.47 $585.81 $717.6242 $784.14 $960.57 $746.40 $914.34 $596.16 $730.2943 $803.07 $983.76 $764.43 $936.42 $610.56 $747.9344 $826.74 $1,012.76 $786.96 $964.02 $628.55 $769.9845 $854.56 $1,046.84 $813.43 $996.46 $649.70 $795.8846 $887.70 $1,087.43 $844.98 $1,035.10 $674.90 $826.7547 $924.98 $1,133.10 $880.47 $1,078.57 $703.24 $861.4748 $967.59 $1,185.30 $921.03 $1,128.26 $735.64 $901.1549 $1,009.61 $1,236.77 $961.02 $1,177.25 $767.58 $940.2950 $1,056.95 $1,453.31 $1,006.09 $1,383.37 $803.57 $1,104.9251 $1,103.71 $1,517.60 $1,050.59 $1,444.56 $839.12 $1,153.7952 $1,155.19 $1,588.39 $1,099.60 $1,511.95 $878.26 $1,207.6153 $1,207.27 $1,660.00 $1,149.17 $1,580.11 $917.86 $1,262.0554 $1,263.49 $1,737.30 $1,202.69 $1,653.70 $960.60 $1,320.8355 $1,319.71 $1,814.61 $1,256.20 $1,727.28 $1,003.34 $1,379.6056 $1,380.67 $1,898.42 $1,314.23 $1,807.06 $1,049.69 $1,443.3257 $1,442.22 $1,983.05 $1,372.81 $1,887.61 $1,096.48 $1,507.6658 $1,507.91 $2,073.37 $1,435.34 $1,973.59 $1,146.42 $1,576.3359 $1,540.46 $2,118.13 $1,466.32 $2,016.19 $1,171.17 $1,610.3660 $1,606.15 $2,208.45 $1,528.85 $2,102.17 $1,221.11 $1,679.0361 $1,662.96 $2,286.57 $1,582.93 $2,176.53 $1,264.30 $1,738.4262 $1,700.24 $2,337.83 $1,618.42 $2,225.33 $1,292.65 $1,777.3963 $1,746.99 $2,402.12 $1,662.92 $2,286.52 $1,328.19 $1,826.27

64+ $1,775.40 $2,441.18 $1,689.96 $2,323.70 $1,349.79 $1,855.96


PPOJuly 1, 2020

Yes



8

31609PA0150025

16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.2016884.WR-I Rev. 1.20


88

YesYes

Personal Choice PPO Gold Preferred $40/$80/$600Personal Choice PPO Platinum Preferred $20/$40/$25031609PA0150026 31609PA0150027


RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$3,750 $1,80030% 0%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$337.95 $337.95 $276.13 $276.13 $384.36 $384.36$367.99 $367.99 $300.67 $300.67 $418.52 $418.52$379.47 $379.47 $310.06 $310.06 $431.59 $431.59$390.96 $390.96 $319.44 $319.44 $444.65 $444.65$403.33 $403.33 $329.55 $329.55 $458.72 $458.72$415.70 $415.70 $339.65 $339.65 $472.79 $472.79$428.51 $428.51 $350.12 $350.12 $487.36 $487.36$441.76 $496.98 $360.95 $406.07 $502.43 $565.23$441.76 $496.98 $360.95 $406.07 $502.43 $565.23$441.76 $496.98 $360.95 $406.07 $502.43 $565.23$441.76 $496.98 $360.95 $406.07 $502.43 $565.23$443.53 $498.97 $362.39 $407.69 $504.44 $567.49$452.36 $508.91 $369.61 $415.81 $514.49 $578.80$462.96 $520.84 $378.28 $425.56 $526.55 $592.36$480.19 $540.22 $392.35 $441.40 $546.14 $614.41$494.33 $556.12 $403.90 $454.39 $562.22 $632.50$501.40 $589.14 $409.68 $481.37 $570.26 $670.05$512.00 $601.60 $418.34 $491.55 $582.32 $684.22$522.60 $614.06 $427.00 $501.73 $594.37 $698.39$529.23 $621.84 $432.42 $508.09 $601.91 $707.25$536.30 $630.15 $438.19 $514.88 $609.95 $716.69$539.83 $634.30 $441.08 $518.27 $613.97 $721.41$543.36 $638.45 $443.97 $521.66 $617.99 $726.14$546.90 $642.61 $446.86 $525.06 $622.01 $730.86$550.43 $646.76 $449.74 $528.45 $626.03 $735.58$557.50 $655.06 $455.52 $535.23 $634.07 $745.03$564.57 $691.60 $461.29 $565.09 $642.11 $786.58$575.17 $704.59 $469.96 $575.70 $654.16 $801.35$585.33 $717.03 $478.26 $585.87 $665.72 $815.51$599.47 $734.35 $489.81 $600.02 $681.80 $835.20$617.14 $755.99 $504.25 $617.70 $701.89 $859.82$637.90 $781.43 $521.21 $638.48 $725.51 $888.75$662.64 $811.73 $541.43 $663.25 $753.65 $923.22$690.47 $845.83 $564.16 $691.10 $785.30 $961.99$722.28 $884.79 $590.15 $722.94 $821.47 $1,006.30$753.64 $923.21 $615.78 $754.33 $857.15 $1,050.00$788.98 $1,084.85 $644.66 $886.40 $897.34 $1,233.84$823.88 $1,132.84 $673.17 $925.61 $937.03 $1,288.42$862.32 $1,185.68 $704.57 $968.79 $980.74 $1,348.52$901.19 $1,239.14 $736.34 $1,012.46 $1,024.96 $1,409.32$943.16 $1,296.84 $770.63 $1,059.61 $1,072.69 $1,474.95$985.12 $1,354.55 $804.92 $1,106.76 $1,120.42 $1,540.58

$1,030.63 $1,417.11 $842.10 $1,157.88 $1,172.17 $1,611.73$1,076.57 $1,480.28 $879.64 $1,209.50 $1,224.42 $1,683.58$1,125.60 $1,547.71 $919.70 $1,264.59 $1,280.19 $1,760.26$1,149.90 $1,581.11 $939.55 $1,291.89 $1,307.83 $1,798.26$1,198.94 $1,648.54 $979.62 $1,346.98 $1,363.60 $1,874.94$1,241.35 $1,706.85 $1,014.27 $1,394.62 $1,411.83 $1,941.26$1,269.18 $1,745.12 $1,037.01 $1,425.89 $1,443.48 $1,984.79$1,304.08 $1,793.10 $1,065.52 $1,465.10 $1,483.17 $2,039.36$1,325.28 $1,822.26 $1,082.85 $1,488.92 $1,507.29 $2,072.52

September 30, 2020

$8,150Yes



Silver

31609PA0150029

Yes

16884.WR-I Rev. 1.208

31609PA0150028

$6,500


$1,50020%


Platinum

31609PA0150030Personal Choice PPO Platinum HSA-50 $1,800/100%

816884.WR-I Rev. 1.20

Personal Choice Network

0% after ded

Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$2,400 $2,10010% 0%

$25/$50 20% after ded$6,900 $6,900 $6,900

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$320.47 $320.47 $372.78 $372.78 $291.01 $291.01$348.95 $348.95 $405.91 $405.91 $316.87 $316.87$359.84 $359.84 $418.58 $418.58 $326.76 $326.76$370.74 $370.74 $431.25 $431.25 $336.65 $336.65$382.46 $382.46 $444.90 $444.90 $347.31 $347.31$394.19 $394.19 $458.54 $458.54 $357.96 $357.96$406.34 $406.34 $472.67 $472.67 $368.99 $368.99$418.91 $471.27 $487.29 $548.20 $380.40 $427.95$418.91 $471.27 $487.29 $548.20 $380.40 $427.95$418.91 $471.27 $487.29 $548.20 $380.40 $427.95$418.91 $471.27 $487.29 $548.20 $380.40 $427.95$420.59 $473.16 $489.24 $550.39 $381.92 $429.66$428.96 $482.58 $498.98 $561.36 $389.53 $438.22$439.02 $493.89 $510.68 $574.51 $398.66 $448.49$455.36 $512.27 $529.68 $595.89 $413.49 $465.18$468.76 $527.36 $545.28 $613.44 $425.67 $478.88$475.46 $558.67 $553.07 $649.86 $431.75 $507.31$485.52 $570.48 $564.77 $663.60 $440.88 $518.04$495.57 $582.30 $576.46 $677.35 $450.01 $528.77$501.85 $589.68 $583.77 $685.93 $455.72 $535.47$508.56 $597.55 $591.57 $695.09 $461.81 $542.62$511.91 $601.49 $595.47 $699.68 $464.85 $546.20$515.26 $605.43 $599.37 $704.26 $467.89 $549.77$518.61 $609.37 $603.27 $708.84 $470.94 $553.35$521.96 $613.31 $607.16 $713.42 $473.98 $556.92$528.66 $621.18 $614.96 $722.58 $480.06 $564.08$535.37 $655.82 $622.76 $762.88 $486.15 $595.54$545.42 $668.14 $634.45 $777.20 $495.28 $606.72$555.06 $679.94 $645.66 $790.93 $504.03 $617.44$568.46 $696.36 $661.25 $810.03 $516.20 $632.35$585.22 $716.89 $680.74 $833.91 $531.42 $650.99$604.91 $741.01 $703.65 $861.97 $549.30 $672.89$628.37 $769.75 $730.94 $895.40 $570.60 $698.99$654.76 $802.08 $761.63 $933.00 $594.57 $728.34$684.92 $839.02 $796.72 $975.98 $621.95 $761.89$714.66 $875.46 $831.32 $1,018.36 $648.96 $794.98$748.17 $1,028.74 $870.30 $1,196.66 $679.39 $934.17$781.27 $1,074.24 $908.80 $1,249.59 $709.45 $975.49$817.71 $1,124.35 $951.19 $1,307.89 $742.54 $1,020.99$854.58 $1,175.04 $994.07 $1,366.85 $776.02 $1,067.02$894.37 $1,229.76 $1,040.36 $1,430.50 $812.15 $1,116.71$934.17 $1,284.48 $1,086.66 $1,494.15 $848.29 $1,166.40$977.32 $1,343.81 $1,136.85 $1,563.17 $887.47 $1,220.28

$1,020.88 $1,403.72 $1,187.53 $1,632.85 $927.03 $1,274.67$1,067.38 $1,467.65 $1,241.61 $1,707.22 $969.26 $1,332.73$1,090.42 $1,499.33 $1,268.42 $1,744.07 $990.18 $1,361.50$1,136.92 $1,563.27 $1,322.51 $1,818.44 $1,032.41 $1,419.56$1,177.14 $1,618.56 $1,369.28 $1,882.77 $1,068.92 $1,469.77$1,203.53 $1,654.85 $1,399.98 $1,924.98 $1,092.89 $1,502.72$1,236.62 $1,700.36 $1,438.48 $1,977.91 $1,122.94 $1,544.04$1,256.73 $1,728.00 $1,461.87 $2,010.07 $1,141.20 $1,569.15

16884.WR-I Rev. 1.20

Gold Gold Gold

31609PA0150031 31609PA0150032 31609PA0150033Personal Choice PPO Gold HSA-25 $2,400/$25/$50/90%Personal Choice PPO Gold HSA-0 $2,100/100%Personal Choice PPO Gold HSA-25 $2,600/80%

8 8 816884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20

Personal Choice Network Personal Choice Network Personal Choice Network

$2,60020%

0% after ded

Yes Yes Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$2,100 $3,00030% 10%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$274.08 $274.08 $301.72 $301.72 $206.47 $206.47$298.45 $298.45 $328.54 $328.54 $224.83 $224.83$307.76 $307.76 $338.80 $338.80 $231.84 $231.84$317.08 $317.08 $349.05 $349.05 $238.86 $238.86$327.11 $327.11 $360.10 $360.10 $246.42 $246.42$337.14 $337.14 $371.14 $371.14 $253.98 $253.98$347.53 $347.53 $382.58 $382.58 $261.80 $261.80$358.28 $403.07 $394.41 $443.71 $269.90 $303.64$358.28 $403.07 $394.41 $443.71 $269.90 $303.64$358.28 $403.07 $394.41 $443.71 $269.90 $303.64$358.28 $403.07 $394.41 $443.71 $269.90 $303.64$359.71 $404.68 $395.99 $445.49 $270.98 $304.85$366.88 $412.74 $403.88 $454.36 $276.38 $310.92$375.48 $422.41 $413.34 $465.01 $282.86 $318.21$389.45 $438.13 $428.72 $482.31 $293.38 $330.05$400.92 $451.03 $441.34 $496.51 $302.02 $339.77$406.65 $477.81 $447.66 $526.00 $306.34 $359.95$415.25 $487.91 $457.12 $537.12 $312.81 $367.56$423.85 $498.02 $466.59 $548.24 $319.29 $375.17$429.22 $504.33 $472.50 $555.19 $323.34 $379.92$434.95 $511.07 $478.81 $562.61 $327.66 $385.00$437.82 $514.44 $481.97 $566.31 $329.82 $387.54$440.68 $517.80 $485.12 $570.02 $331.98 $390.07$443.55 $521.17 $488.28 $573.73 $334.14 $392.61$446.42 $524.54 $491.43 $577.44 $336.30 $395.15$452.15 $531.28 $497.75 $584.85 $340.61 $400.22$457.88 $560.91 $504.06 $617.47 $344.93 $422.54$466.48 $571.44 $513.52 $629.06 $351.41 $430.48$474.72 $581.53 $522.59 $640.18 $357.62 $438.08$486.19 $595.58 $535.21 $655.64 $366.25 $448.66$500.52 $613.13 $550.99 $674.96 $377.05 $461.89$517.36 $633.76 $569.53 $697.67 $389.74 $477.43$537.42 $658.34 $591.62 $724.73 $404.85 $495.94$559.99 $685.99 $616.46 $755.17 $421.85 $516.77$585.79 $717.59 $644.86 $789.95 $441.29 $540.58$611.23 $748.75 $672.86 $824.26 $460.45 $564.05$639.89 $879.85 $704.42 $968.57 $482.04 $662.81$668.19 $918.76 $735.57 $1,011.42 $503.36 $692.12$699.36 $961.62 $769.89 $1,058.60 $526.84 $724.41$730.89 $1,004.98 $804.60 $1,106.32 $550.60 $757.07$764.93 $1,051.78 $842.07 $1,157.84 $576.24 $792.33$798.96 $1,098.58 $879.53 $1,209.36 $601.88 $827.58$835.87 $1,149.32 $920.16 $1,265.22 $629.68 $865.81$873.13 $1,200.55 $961.18 $1,321.62 $657.75 $904.40$912.90 $1,255.23 $1,004.96 $1,381.82 $687.71 $945.59$932.60 $1,282.33 $1,026.65 $1,411.64 $702.55 $966.01$972.37 $1,337.01 $1,070.43 $1,471.84 $732.51 $1,007.20

$1,006.77 $1,384.30 $1,108.29 $1,523.90 $758.42 $1,042.83$1,029.34 $1,415.34 $1,133.14 $1,558.07 $775.42 $1,066.21$1,057.64 $1,454.26 $1,164.30 $1,600.91 $796.74 $1,095.52$1,074.84 $1,477.91 $1,183.23 $1,626.94 $809.70 $1,113.34

16884.WR-I Rev. 1.20

Silver

31609PA0150034 31609PA0150035 31609PA0150036Personal Choice PPO Silver HSA-0 $2,100/70%Personal Choice PPO Silver HSA-0 $3,000/90% Personal Choice PPO Bronze HSA-0 $5,200/50%

8 8 816884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20


$5,200Silver Bronze

50%

Yes Yes Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$6,900 $3,4000% 0%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$222.32 $222.32 $338.48 $338.48 $337.63 $337.63$242.08 $242.08 $368.57 $368.57 $367.64 $367.64$249.63 $249.63 $380.07 $380.07 $379.12 $379.12$257.19 $257.19 $391.58 $391.58 $390.59 $390.59$265.33 $265.33 $403.97 $403.97 $402.95 $402.95$273.46 $273.46 $416.35 $416.35 $415.31 $415.31$281.89 $281.89 $429.19 $429.19 $428.11 $428.11$290.61 $326.94 $442.46 $497.77 $441.35 $496.52$290.61 $326.94 $442.46 $497.77 $441.35 $496.52$290.61 $326.94 $442.46 $497.77 $441.35 $496.52$290.61 $326.94 $442.46 $497.77 $441.35 $496.52$291.77 $328.24 $444.23 $499.76 $443.12 $498.50$297.58 $334.78 $453.08 $509.71 $451.94 $508.44$304.56 $342.63 $463.70 $521.66 $462.53 $520.35$315.89 $355.38 $480.95 $541.07 $479.75 $539.72$325.19 $365.84 $495.11 $557.00 $493.87 $555.60$329.84 $387.56 $502.19 $590.08 $500.93 $588.60$336.82 $395.76 $512.81 $602.55 $511.52 $601.04$343.79 $403.96 $523.43 $615.03 $522.12 $613.49$348.15 $409.08 $530.07 $622.83 $528.74 $621.27$352.80 $414.54 $537.15 $631.15 $535.80 $629.56$355.13 $417.27 $540.69 $635.31 $539.33 $633.71$357.45 $420.00 $544.23 $639.47 $542.86 $637.86$359.78 $422.74 $547.77 $643.62 $546.39 $642.01$362.10 $425.47 $551.31 $647.78 $549.92 $646.16$366.75 $430.93 $558.38 $656.10 $556.98 $654.46$371.40 $454.96 $565.46 $692.69 $564.05 $690.96$378.37 $463.51 $576.08 $705.70 $574.64 $703.93$385.06 $471.70 $586.26 $718.17 $584.79 $716.37$394.36 $483.09 $600.42 $735.51 $598.91 $733.67$405.98 $497.33 $618.12 $757.19 $616.57 $755.29$419.64 $514.06 $638.91 $782.67 $637.31 $780.70$435.92 $534.00 $663.69 $813.02 $662.03 $810.98$454.22 $556.42 $691.56 $847.17 $689.83 $845.04$475.15 $582.06 $723.42 $886.19 $721.61 $883.97$495.78 $607.33 $754.84 $924.68 $752.94 $922.36$519.03 $713.67 $790.23 $1,086.57 $788.25 $1,083.85$541.99 $745.23 $825.19 $1,134.63 $823.12 $1,131.79$567.27 $780.00 $863.68 $1,187.56 $861.52 $1,184.58$592.84 $815.16 $902.62 $1,241.10 $900.35 $1,237.99$620.45 $853.12 $944.65 $1,298.90 $942.28 $1,295.64$648.06 $891.08 $986.69 $1,356.69 $984.21 $1,353.29$677.99 $932.24 $1,032.26 $1,419.36 $1,029.67 $1,415.80$708.22 $973.80 $1,078.28 $1,482.63 $1,075.57 $1,478.91$740.47 $1,018.15 $1,127.39 $1,550.16 $1,124.56 $1,546.27$756.46 $1,040.13 $1,151.72 $1,583.62 $1,148.83 $1,579.65$788.72 $1,084.48 $1,200.84 $1,651.15 $1,197.82 $1,647.01$816.61 $1,122.84 $1,243.31 $1,709.55 $1,240.19 $1,705.27$834.92 $1,148.02 $1,271.19 $1,747.88 $1,268.00 $1,743.50$857.88 $1,179.59 $1,306.14 $1,795.95 $1,302.87 $1,791.44$871.83 $1,198.77 $1,327.38 $1,825.15 $1,324.05 $1,820.57

31609PA0150037 31609PA0150039 31609PA0150047Personal Choice PPO Bronze HSA-0 $6,900/100%Personal Choice PPO Gold HRA-25 $3,400/100%Personal Choice PPO Gold Classic $2,500 $40/$80/100%



$2,500Bronze Gold Gold

0%

$5,000$40 no ded/$80 no ded

Yes Yes Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$238.07 $238.07 $244.75 $244.75 $303.65 $303.65$259.23 $259.23 $266.51 $266.51 $330.64 $330.64$267.32 $267.32 $274.83 $274.83 $340.96 $340.96$275.41 $275.41 $283.15 $283.15 $351.28 $351.28$284.13 $284.13 $292.11 $292.11 $362.40 $362.40$292.84 $292.84 $301.06 $301.06 $373.51 $373.51$301.86 $301.86 $310.34 $310.34 $385.02 $385.02$311.20 $350.10 $319.94 $359.93 $396.93 $446.55$311.20 $350.10 $319.94 $359.93 $396.93 $446.55$311.20 $350.10 $319.94 $359.93 $396.93 $446.55$311.20 $350.10 $319.94 $359.93 $396.93 $446.55$312.44 $351.50 $321.22 $361.37 $398.52 $448.33$318.67 $358.50 $327.62 $368.57 $406.46 $457.26$326.14 $366.90 $335.30 $377.21 $415.98 $467.98$338.27 $380.56 $347.77 $391.25 $431.46 $485.40$348.23 $391.76 $358.01 $402.76 $444.16 $499.69$353.21 $415.02 $363.13 $426.68 $450.52 $529.36$360.68 $423.80 $370.81 $435.70 $460.04 $540.55$368.15 $432.58 $378.49 $444.72 $469.57 $551.74$372.82 $438.06 $383.29 $450.36 $475.52 $558.74$377.80 $443.91 $388.41 $456.38 $481.87 $566.20$380.29 $446.84 $390.97 $459.39 $485.05 $569.93$382.78 $449.76 $393.53 $462.39 $488.22 $573.66$385.27 $452.69 $396.09 $465.40 $491.40 $577.39$387.76 $455.61 $398.65 $468.41 $494.57 $581.13$392.73 $461.46 $403.76 $474.42 $500.93 $588.59$397.71 $487.20 $408.88 $500.88 $507.28 $621.41$405.18 $496.35 $416.56 $510.29 $516.80 $633.08$412.34 $505.12 $423.92 $519.30 $525.93 $644.27$422.30 $517.32 $434.16 $531.84 $538.63 $659.83$434.75 $532.56 $446.96 $547.52 $554.51 $679.28$449.37 $550.48 $461.99 $565.94 $573.17 $702.13$466.80 $571.83 $479.91 $587.89 $595.40 $729.36$486.41 $595.85 $500.07 $612.58 $620.40 $759.99$508.81 $623.29 $523.10 $640.80 $648.98 $795.00$530.91 $650.36 $545.82 $668.63 $677.16 $829.52$555.80 $764.23 $571.41 $785.69 $708.92 $974.76$580.39 $798.03 $596.69 $820.45 $740.27 $1,017.88$607.46 $835.26 $624.52 $858.72 $774.81 $1,065.36$634.85 $872.92 $652.68 $897.43 $809.74 $1,113.39$664.41 $913.57 $683.07 $939.22 $847.45 $1,165.24$693.98 $954.22 $713.47 $981.02 $885.15 $1,217.09$726.03 $998.29 $746.42 $1,026.33 $926.04 $1,273.30$758.39 $1,042.79 $779.69 $1,072.08 $967.32 $1,330.06$792.94 $1,090.29 $815.21 $1,120.91 $1,011.38 $1,390.64$810.05 $1,113.82 $832.80 $1,145.11 $1,033.21 $1,420.66$844.60 $1,161.32 $868.32 $1,193.94 $1,077.27 $1,481.24$874.47 $1,202.40 $899.03 $1,236.17 $1,115.37 $1,533.64$894.08 $1,229.36 $919.19 $1,263.88 $1,140.38 $1,568.02$918.66 $1,263.16 $944.46 $1,298.64 $1,171.74 $1,611.14$933.60 $1,283.70 $959.82 $1,319.75 $1,190.79 $1,637.34

31609PA0150048 31609PA0150049 31609PA0150050Personal Choice PPO Silver Classic $5,000/$50/$100/90%Personal Choice PPO Silver Secure $4,750/$40/$80/$600Personal Choice PPO Silver HSA-0 $3,500/100%

16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.208 8 8

Personal Choice Network Personal Choice Network Personal Choice NetworkSilver Silver Silver

$5,000 $4,750 $3,50010% 0% 0%

$50 no ded/$100 no ded $40 no ded/$80 no ded 0% after ded$8,150 $8,150 $6,900

Yes Yes Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco$253.26 $253.26$275.77 $275.77$284.38 $284.38$292.99 $292.99$302.26 $302.26$311.53 $311.53$321.13 $321.13$331.06 $372.44$331.06 $372.44$331.06 $372.44$331.06 $372.44$332.38 $373.93$339.01 $381.38$346.95 $390.32$359.86 $404.84$370.46 $416.76$375.75 $441.51$383.70 $450.85$391.64 $460.18$396.61 $466.02$401.91 $472.24$404.56 $475.35$407.20 $478.46$409.85 $481.58$412.50 $484.69$417.80 $490.91$423.09 $518.29$431.04 $528.02$438.65 $537.35$449.25 $550.33$462.49 $566.55$478.05 $585.61$496.59 $608.32$517.45 $633.87$541.28 $663.07$564.79 $691.87$591.27 $813.00$617.43 $848.96$646.23 $888.57$675.36 $928.62$706.81 $971.87$738.26 $1,015.11$772.36 $1,062.00$806.79 $1,109.34$843.54 $1,159.87$861.75 $1,184.91$898.50 $1,235.43$930.28 $1,279.13$951.14 $1,307.81$977.29 $1,343.77$993.18 $1,365.62


16884.WR-I Rev. 1.208

Personal Choice NetworkSilver

$3,00020%

20% after ded/20% after ded$6,900

Yes

RATE PAGES





Plan Design Summary

RATE PAGES


RATING AREA 812,705 14,784 10,778 22,091 11,234





RATE PAGES









Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco0-14 $459.59 $459.59 $437.47 $437.47 $349.41 $349.4115 $500.44 $500.44 $476.35 $476.35 $380.47 $380.4716 $516.06 $516.06 $491.22 $491.22 $392.35 $392.3517 $531.68 $531.68 $506.09 $506.09 $404.22 $404.2218 $548.50 $548.50 $522.10 $522.10 $417.01 $417.0119 $565.32 $565.32 $538.11 $538.11 $429.80 $429.8020 $582.75 $582.75 $554.69 $554.69 $443.05 $443.0521 $600.77 $675.87 $571.85 $643.33 $456.75 $513.8422 $600.77 $675.87 $571.85 $643.33 $456.75 $513.8423 $600.77 $675.87 $571.85 $643.33 $456.75 $513.8424 $600.77 $675.87 $571.85 $643.33 $456.75 $513.8425 $603.17 $678.57 $574.14 $645.90 $458.58 $515.9026 $615.19 $692.09 $585.57 $658.77 $467.71 $526.1827 $629.61 $708.31 $599.30 $674.21 $478.67 $538.5128 $653.04 $734.67 $621.60 $699.30 $496.49 $558.5529 $672.26 $756.29 $639.90 $719.89 $511.10 $574.9930 $681.87 $801.20 $649.05 $762.63 $518.41 $609.1331 $696.29 $818.14 $662.77 $778.76 $529.37 $622.0132 $710.71 $835.09 $676.50 $794.89 $540.34 $634.8933 $719.72 $845.67 $685.08 $804.96 $547.19 $642.9434 $729.33 $856.97 $694.23 $815.72 $554.49 $651.5335 $734.14 $862.62 $698.80 $821.09 $558.15 $655.8236 $738.95 $868.26 $703.38 $826.47 $561.80 $660.1237 $743.75 $873.91 $707.95 $831.84 $565.46 $664.4138 $748.56 $879.56 $712.53 $837.22 $569.11 $668.7039 $758.17 $890.85 $721.67 $847.97 $576.42 $677.2940 $767.78 $940.54 $730.82 $895.26 $583.73 $715.0641 $782.20 $958.20 $744.55 $912.07 $594.69 $728.4942 $796.02 $975.12 $757.70 $928.18 $605.19 $741.3643 $815.24 $998.67 $776.00 $950.60 $619.81 $759.2744 $839.28 $1,028.11 $798.87 $978.62 $638.08 $781.6545 $867.51 $1,062.70 $825.75 $1,011.55 $659.55 $807.9546 $901.16 $1,103.91 $857.78 $1,050.77 $685.13 $839.2847 $939.00 $1,150.28 $893.80 $1,094.91 $713.90 $874.5348 $982.26 $1,203.27 $934.97 $1,145.34 $746.79 $914.8149 $1,024.91 $1,255.52 $975.58 $1,195.08 $779.22 $954.5450 $1,072.98 $1,475.34 $1,021.32 $1,404.32 $815.76 $1,121.6651 $1,120.44 $1,540.60 $1,066.50 $1,466.44 $851.84 $1,171.2852 $1,172.70 $1,612.47 $1,116.25 $1,534.85 $891.58 $1,225.9253 $1,225.57 $1,685.16 $1,166.57 $1,604.04 $931.77 $1,281.1854 $1,282.64 $1,763.64 $1,220.90 $1,678.74 $975.16 $1,340.8555 $1,339.72 $1,842.11 $1,275.23 $1,753.44 $1,018.55 $1,400.5156 $1,401.60 $1,927.20 $1,334.13 $1,834.42 $1,065.60 $1,465.2057 $1,464.08 $2,013.11 $1,393.60 $1,916.20 $1,113.10 $1,530.5158 $1,530.76 $2,104.80 $1,457.07 $2,003.48 $1,163.80 $1,600.2259 $1,563.80 $2,150.23 $1,488.53 $2,046.72 $1,188.92 $1,634.7760 $1,630.49 $2,241.92 $1,552.00 $2,134.00 $1,239.62 $1,704.4861 $1,688.16 $2,321.23 $1,606.90 $2,209.49 $1,283.47 $1,764.7762 $1,726.01 $2,373.27 $1,642.93 $2,259.02 $1,312.24 $1,804.3363 $1,773.47 $2,438.53 $1,688.10 $2,321.14 $1,348.33 $1,853.95

64+ $1,802.31 $2,478.18 $1,715.55 $2,358.88 $1,370.25 $1,884.09


PPOOctober 1, 2020

Yes



8

31609PA0150025

16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.2016884.WR-I Rev. 1.20


88

YesYes

Personal Choice PPO Gold Preferred $40/$80/$600Personal Choice PPO Platinum Preferred $20/$40/$25031609PA0150026 31609PA0150027


RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$3,750 $1,80030% 0%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$343.06 $343.06 $280.31 $280.31 $390.19 $390.19$373.56 $373.56 $305.23 $305.23 $424.87 $424.87$385.22 $385.22 $314.75 $314.75 $438.13 $438.13$396.88 $396.88 $324.28 $324.28 $451.39 $451.39$409.43 $409.43 $334.54 $334.54 $465.68 $465.68$421.99 $421.99 $344.80 $344.80 $479.96 $479.96$435.00 $435.00 $355.43 $355.43 $494.75 $494.75$448.45 $504.51 $366.42 $412.22 $510.05 $573.81$448.45 $504.51 $366.42 $412.22 $510.05 $573.81$448.45 $504.51 $366.42 $412.22 $510.05 $573.81$448.45 $504.51 $366.42 $412.22 $510.05 $573.81$450.24 $506.52 $367.89 $413.87 $512.09 $576.10$459.21 $516.61 $375.21 $422.12 $522.29 $587.58$469.98 $528.72 $384.01 $432.01 $534.53 $601.35$487.47 $548.40 $398.30 $448.09 $554.42 $623.73$501.82 $564.54 $410.02 $461.28 $570.75 $642.09$508.99 $598.06 $415.89 $488.67 $578.91 $680.22$519.75 $610.71 $424.68 $499.00 $591.15 $694.60$530.52 $623.36 $433.47 $509.33 $603.39 $708.98$537.24 $631.26 $438.97 $515.79 $611.04 $717.97$544.42 $639.69 $444.83 $522.68 $619.20 $727.56$548.01 $643.91 $447.77 $526.12 $623.28 $732.36$551.59 $648.12 $450.70 $529.57 $627.36 $737.15$555.18 $652.34 $453.63 $533.01 $631.44 $741.94$558.77 $656.55 $456.56 $536.46 $635.52 $746.74$565.94 $664.98 $462.42 $543.35 $643.68 $756.33$573.12 $702.07 $468.28 $573.65 $651.84 $798.51$583.88 $715.26 $477.08 $584.42 $664.09 $813.50$594.20 $727.89 $485.51 $594.75 $675.82 $827.87$608.55 $745.47 $497.23 $609.11 $692.14 $847.87$626.48 $767.44 $511.89 $627.06 $712.54 $872.86$647.56 $793.26 $529.11 $648.16 $736.51 $902.23$672.68 $824.03 $549.63 $673.30 $765.08 $937.22$700.93 $858.64 $572.71 $701.58 $797.21 $976.58$733.22 $898.19 $599.10 $733.89 $833.93 $1,021.57$765.06 $937.19 $625.11 $765.76 $870.15 $1,065.93$800.93 $1,101.28 $654.43 $899.84 $910.95 $1,252.56$836.36 $1,149.99 $683.37 $939.64 $951.24 $1,307.96$875.37 $1,203.64 $715.25 $983.47 $995.62 $1,368.97$914.84 $1,257.90 $747.50 $1,027.81 $1,040.50 $1,430.69$957.44 $1,316.48 $782.31 $1,075.67 $1,088.96 $1,497.32

$1,000.04 $1,375.06 $817.12 $1,123.54 $1,137.41 $1,563.94$1,046.23 $1,438.57 $854.86 $1,175.43 $1,189.95 $1,636.18$1,092.87 $1,502.70 $892.97 $1,227.83 $1,242.99 $1,709.11$1,142.65 $1,571.14 $933.64 $1,283.75 $1,299.61 $1,786.96$1,167.32 $1,605.06 $953.79 $1,311.46 $1,327.66 $1,825.53$1,217.09 $1,673.50 $994.46 $1,367.39 $1,384.28 $1,903.38$1,260.14 $1,732.70 $1,029.64 $1,415.76 $1,433.24 $1,970.71$1,288.40 $1,771.55 $1,052.72 $1,447.50 $1,465.37 $2,014.89$1,323.82 $1,820.26 $1,081.67 $1,487.30 $1,505.67 $2,070.29$1,345.35 $1,849.86 $1,099.26 $1,511.48 $1,530.15 $2,103.96

December 31, 2020

$8,150Yes



Silver

31609PA0150029

Yes

16884.WR-I Rev. 1.208

31609PA0150028

$6,500


$1,50020%


Platinum

31609PA0150030Personal Choice PPO Platinum HSA-50 $1,800/100%

816884.WR-I Rev. 1.20

Personal Choice Network

0% after ded

Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$2,400 $2,10010% 0%

$25/$50 20% after ded$6,900 $6,900 $6,900

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$325.32 $325.32 $378.42 $378.42 $295.42 $295.42$354.23 $354.23 $412.06 $412.06 $321.68 $321.68$365.29 $365.29 $424.92 $424.92 $331.72 $331.72$376.35 $376.35 $437.78 $437.78 $341.76 $341.76$388.25 $388.25 $451.63 $451.63 $352.57 $352.57$400.16 $400.16 $465.48 $465.48 $363.39 $363.39$412.49 $412.49 $479.83 $479.83 $374.58 $374.58$425.25 $478.41 $494.67 $556.50 $386.17 $434.44$425.25 $478.41 $494.67 $556.50 $386.17 $434.44$425.25 $478.41 $494.67 $556.50 $386.17 $434.44$425.25 $478.41 $494.67 $556.50 $386.17 $434.44$426.95 $480.32 $496.65 $558.73 $387.71 $436.18$435.46 $489.89 $506.54 $569.86 $395.44 $444.87$445.66 $501.37 $518.41 $583.22 $404.71 $455.29$462.25 $520.03 $537.71 $604.92 $419.77 $472.24$475.85 $535.34 $553.54 $622.73 $432.12 $486.14$482.66 $567.12 $561.45 $659.70 $438.30 $515.01$492.86 $579.12 $573.32 $673.65 $447.57 $525.90$503.07 $591.11 $585.19 $687.60 $456.84 $536.79$509.45 $598.60 $592.61 $696.32 $462.63 $543.59$516.25 $606.60 $600.53 $705.62 $468.81 $550.85$519.66 $610.60 $604.49 $710.27 $471.90 $554.48$523.06 $614.59 $608.44 $714.92 $474.99 $558.11$526.46 $618.59 $612.40 $719.57 $478.08 $561.74$529.86 $622.59 $616.36 $724.22 $481.17 $565.37$536.67 $630.58 $624.27 $733.52 $487.35 $572.63$543.47 $665.75 $632.19 $774.43 $493.53 $604.57$553.68 $678.25 $644.06 $788.97 $502.79 $615.92$563.46 $690.23 $655.44 $802.91 $511.68 $626.80$577.06 $706.90 $671.27 $822.30 $524.03 $641.94$594.07 $727.74 $691.05 $846.54 $539.48 $660.86$614.06 $752.22 $714.30 $875.02 $557.63 $683.10$637.88 $781.40 $742.01 $908.96 $579.26 $709.59$664.67 $814.22 $773.17 $947.13 $603.58 $739.39$695.28 $851.72 $808.79 $990.76 $631.39 $773.45$725.48 $888.71 $843.91 $1,033.79 $658.81 $807.04$759.50 $1,044.31 $883.48 $1,214.79 $689.70 $948.34$793.09 $1,090.50 $922.56 $1,268.52 $720.21 $990.28$830.09 $1,141.37 $965.60 $1,327.69 $753.80 $1,036.48$867.51 $1,192.83 $1,009.13 $1,387.55 $787.79 $1,083.21$907.91 $1,248.37 $1,056.12 $1,452.17 $824.47 $1,133.65$948.31 $1,303.92 $1,103.11 $1,516.78 $861.16 $1,184.09$992.11 $1,364.15 $1,154.07 $1,586.84 $900.93 $1,238.79

$1,036.33 $1,424.96 $1,205.51 $1,657.58 $941.10 $1,294.01$1,083.54 $1,489.86 $1,260.42 $1,733.08 $983.96 $1,352.95$1,106.93 $1,522.02 $1,287.63 $1,770.49 $1,005.20 $1,382.15$1,154.13 $1,586.93 $1,342.53 $1,845.98 $1,048.07 $1,441.09$1,194.95 $1,643.06 $1,390.02 $1,911.28 $1,085.14 $1,492.06$1,221.74 $1,679.90 $1,421.19 $1,954.13 $1,109.47 $1,525.52$1,255.34 $1,726.09 $1,460.27 $2,007.87 $1,139.97 $1,567.46$1,275.75 $1,754.16 $1,484.01 $2,040.51 $1,158.51 $1,592.95

16884.WR-I Rev. 1.20

Gold Gold Gold

31609PA0150031 31609PA0150032 31609PA0150033Personal Choice PPO Gold HSA-25 $2,400/$25/$50/90%Personal Choice PPO Gold HSA-0 $2,100/100%Personal Choice PPO Gold HSA-25 $2,600/80%

8 8 816884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20


$2,60020%

0% after ded

Yes Yes Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$2,100 $3,00030% 10%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$278.24 $278.24 $306.29 $306.29 $209.60 $209.60$302.97 $302.97 $333.52 $333.52 $228.23 $228.23$312.43 $312.43 $343.93 $343.93 $235.36 $235.36$321.88 $321.88 $354.34 $354.34 $242.48 $242.48$332.07 $332.07 $365.55 $365.55 $250.15 $250.15$342.25 $342.25 $376.76 $376.76 $257.82 $257.82$352.80 $352.80 $388.37 $388.37 $265.77 $265.77$363.71 $409.17 $400.38 $450.43 $273.99 $308.24$363.71 $409.17 $400.38 $450.43 $273.99 $308.24$363.71 $409.17 $400.38 $450.43 $273.99 $308.24$363.71 $409.17 $400.38 $450.43 $273.99 $308.24$365.16 $410.81 $401.98 $452.23 $275.09 $309.47$372.44 $418.99 $409.99 $461.24 $280.57 $315.64$381.17 $428.81 $419.60 $472.05 $287.14 $323.03$395.35 $444.77 $435.21 $489.61 $297.83 $335.06$406.99 $457.87 $448.03 $504.03 $306.59 $344.92$412.81 $485.05 $454.43 $533.96 $310.98 $365.40$421.54 $495.31 $464.04 $545.25 $317.55 $373.13$430.27 $505.57 $473.65 $556.54 $324.13 $380.85$435.72 $511.98 $479.66 $563.59 $328.24 $385.68$441.54 $518.81 $486.06 $571.12 $332.62 $390.83$444.45 $522.23 $489.26 $574.89 $334.82 $393.41$447.36 $525.65 $492.47 $578.65 $337.01 $395.98$450.27 $529.07 $495.67 $582.41 $339.20 $398.56$453.18 $532.49 $498.87 $586.18 $341.39 $401.14$459.00 $539.33 $505.28 $593.70 $345.78 $406.29$464.82 $569.41 $511.69 $626.81 $350.16 $428.95$473.55 $580.10 $521.29 $638.59 $356.73 $437.00$481.92 $590.35 $530.50 $649.87 $363.04 $444.72$493.55 $604.60 $543.32 $665.56 $371.80 $455.46$508.10 $622.43 $559.33 $685.18 $382.76 $468.89$525.20 $643.37 $578.15 $708.23 $395.64 $484.66$545.57 $668.32 $600.57 $735.70 $410.99 $503.46$568.48 $696.39 $625.79 $766.60 $428.25 $524.60$594.67 $728.47 $654.62 $801.91 $447.97 $548.77$620.49 $760.10 $683.05 $836.73 $467.43 $572.60$649.59 $893.18 $715.08 $983.23 $489.35 $672.85$678.32 $932.69 $746.71 $1,026.72 $510.99 $702.61$709.96 $976.20 $781.54 $1,074.62 $534.83 $735.39$741.97 $1,020.21 $816.78 $1,123.07 $558.94 $768.54$776.52 $1,067.72 $854.81 $1,175.37 $584.97 $804.33$811.07 $1,115.23 $892.85 $1,227.67 $611.00 $840.12$848.54 $1,166.74 $934.09 $1,284.37 $639.22 $878.93$886.36 $1,218.75 $975.73 $1,341.62 $667.71 $918.11$926.73 $1,274.26 $1,020.17 $1,402.73 $698.13 $959.92$946.74 $1,301.76 $1,042.19 $1,433.01 $713.20 $980.64$987.11 $1,357.27 $1,086.63 $1,494.12 $743.61 $1,022.46

$1,022.03 $1,405.28 $1,125.07 $1,546.97 $769.91 $1,058.63$1,044.94 $1,436.79 $1,150.29 $1,581.65 $787.17 $1,082.36$1,073.67 $1,476.30 $1,181.92 $1,625.14 $808.82 $1,112.13$1,091.13 $1,500.30 $1,201.14 $1,651.57 $821.97 $1,130.21

16884.WR-I Rev. 1.20

Silver

31609PA0150034 31609PA0150035 31609PA0150036Personal Choice PPO Silver HSA-0 $2,100/70%Personal Choice PPO Silver HSA-0 $3,000/90% Personal Choice PPO Bronze HSA-0 $5,200/50%

8 8 816884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20


$5,200Silver Bronze

50%

Yes Yes Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

$6,900 $3,4000% 0%


Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$225.69 $225.69 $343.62 $343.62 $342.75 $342.75$245.75 $245.75 $374.16 $374.16 $373.22 $373.22$253.42 $253.42 $385.84 $385.84 $384.87 $384.87$261.09 $261.09 $397.52 $397.52 $396.52 $396.52$269.35 $269.35 $410.09 $410.09 $409.06 $409.06$277.61 $277.61 $422.67 $422.67 $421.61 $421.61$286.17 $286.17 $435.69 $435.69 $434.60 $434.60$295.02 $331.90 $449.17 $505.32 $448.04 $504.05$295.02 $331.90 $449.17 $505.32 $448.04 $504.05$295.02 $331.90 $449.17 $505.32 $448.04 $504.05$295.02 $331.90 $449.17 $505.32 $448.04 $504.05$296.20 $333.23 $450.97 $507.34 $449.83 $506.06$302.10 $339.86 $459.95 $517.44 $458.79 $516.14$309.18 $347.83 $470.73 $529.57 $469.55 $528.24$320.69 $360.77 $488.25 $549.28 $487.02 $547.90$330.13 $371.39 $502.62 $565.45 $501.36 $564.03$334.85 $393.45 $509.81 $599.02 $508.53 $597.52$341.93 $401.77 $520.59 $611.69 $519.28 $610.15$349.01 $410.09 $531.37 $624.36 $530.03 $622.79$353.43 $415.28 $538.11 $632.27 $536.75 $630.68$358.15 $420.83 $545.29 $640.72 $543.92 $639.11$360.51 $423.60 $548.89 $644.94 $547.50 $643.32$362.87 $426.38 $552.48 $649.16 $551.09 $647.53$365.23 $429.15 $556.07 $653.39 $554.67 $651.74$367.59 $431.92 $559.67 $657.61 $558.26 $655.95$372.32 $437.47 $566.85 $666.05 $565.43 $664.38$377.04 $461.87 $574.04 $703.20 $572.60 $701.43$384.12 $470.54 $584.82 $716.40 $583.35 $714.60$390.90 $478.85 $595.15 $729.06 $593.65 $727.22$400.34 $490.42 $609.52 $746.67 $607.99 $744.79$412.14 $504.88 $627.49 $768.68 $625.91 $766.74$426.01 $521.86 $648.60 $794.54 $646.97 $792.54$442.53 $542.10 $673.76 $825.35 $672.06 $823.27$461.12 $564.87 $702.05 $860.01 $700.29 $857.85$482.36 $590.89 $734.39 $899.63 $732.55 $897.37$503.30 $616.55 $766.28 $938.70 $764.36 $936.34$526.91 $724.50 $802.22 $1,103.05 $800.20 $1,100.27$550.21 $756.54 $837.70 $1,151.84 $835.59 $1,148.94$575.88 $791.83 $876.78 $1,205.57 $874.57 $1,202.54$601.84 $827.53 $916.31 $1,259.92 $914.00 $1,256.75$629.87 $866.07 $958.98 $1,318.59 $956.57 $1,315.28$657.89 $904.61 $1,001.65 $1,377.27 $999.13 $1,373.80$688.28 $946.39 $1,047.91 $1,440.88 $1,045.28 $1,437.26$718.96 $988.58 $1,094.63 $1,505.11 $1,091.87 $1,501.33$751.71 $1,033.60 $1,144.49 $1,573.67 $1,141.61 $1,569.71$767.94 $1,055.91 $1,169.19 $1,607.64 $1,166.25 $1,603.59$800.68 $1,100.94 $1,219.05 $1,676.19 $1,215.98 $1,671.97$829.01 $1,139.88 $1,262.17 $1,735.48 $1,258.99 $1,731.11$847.59 $1,165.44 $1,290.47 $1,774.39 $1,287.22 $1,769.93$870.90 $1,197.49 $1,325.95 $1,823.18 $1,322.61 $1,818.59$885.06 $1,216.96 $1,347.51 $1,852.83 $1,344.12 $1,848.17

31609PA0150037 31609PA0150039 31609PA0150047Personal Choice PPO Bronze HSA-0 $6,900/100%Personal Choice PPO Gold HRA-25 $3,400/100%Personal Choice PPO Gold Classic $2,500 $40/$80/100%



$2,500Bronze Gold Gold

0%

$5,000$40 no ded/$80 no ded

Yes Yes Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$241.67 $241.67 $248.46 $248.46 $308.25 $308.25$263.15 $263.15 $270.55 $270.55 $335.65 $335.65$271.37 $271.37 $278.99 $278.99 $346.13 $346.13$279.58 $279.58 $287.44 $287.44 $356.60 $356.60$288.43 $288.43 $296.53 $296.53 $367.88 $367.88$297.27 $297.27 $305.63 $305.63 $379.17 $379.17$306.43 $306.43 $315.05 $315.05 $390.85 $390.85$315.91 $355.40 $324.79 $365.39 $402.94 $453.31$315.91 $355.40 $324.79 $365.39 $402.94 $453.31$315.91 $355.40 $324.79 $365.39 $402.94 $453.31$315.91 $355.40 $324.79 $365.39 $402.94 $453.31$317.17 $356.82 $326.09 $366.85 $404.55 $455.12$323.49 $363.93 $332.58 $374.16 $412.61 $464.19$331.07 $372.46 $340.38 $382.93 $422.28 $475.07$343.39 $386.32 $353.05 $397.18 $438.00 $492.75$353.50 $397.69 $363.44 $408.87 $450.89 $507.25$358.56 $421.31 $368.64 $433.15 $457.34 $537.37$366.14 $430.21 $376.43 $442.31 $467.01 $548.73$373.72 $439.12 $384.23 $451.47 $476.68 $560.10$378.46 $444.69 $389.10 $457.19 $482.72 $567.20$383.51 $450.63 $394.30 $463.30 $489.17 $574.77$386.04 $453.60 $396.89 $466.35 $492.39 $578.56$388.57 $456.57 $399.49 $469.40 $495.62 $582.35$391.10 $459.54 $402.09 $472.46 $498.84 $586.14$393.62 $462.51 $404.69 $475.51 $502.06 $589.92$398.68 $468.45 $409.88 $481.61 $508.51 $597.50$403.73 $494.57 $415.08 $508.47 $514.96 $630.82$411.31 $503.86 $422.88 $518.02 $524.63 $642.67$418.58 $512.76 $430.35 $527.17 $533.90 $654.02$428.69 $525.15 $440.74 $539.91 $546.79 $669.82$441.33 $540.62 $453.73 $555.82 $562.91 $689.56$456.17 $558.81 $469.00 $574.52 $581.85 $712.76$473.87 $580.48 $487.19 $596.80 $604.41 $740.40$493.77 $604.86 $507.65 $621.87 $629.80 $771.50$516.51 $632.73 $531.03 $650.51 $658.81 $807.04$538.94 $660.20 $554.09 $678.76 $687.42 $842.08$564.22 $775.80 $580.07 $797.60 $719.65 $989.52$589.17 $810.11 $605.73 $832.88 $751.48 $1,033.29$616.66 $847.90 $633.99 $871.74 $786.54 $1,081.49$644.46 $886.13 $662.57 $911.04 $822.00 $1,130.25$674.47 $927.39 $693.43 $953.46 $860.28 $1,182.88$704.48 $968.66 $724.28 $995.89 $898.56 $1,235.51$737.02 $1,013.40 $757.74 $1,041.89 $940.06 $1,292.58$769.87 $1,058.57 $791.51 $1,088.33 $981.96 $1,350.20$804.94 $1,106.79 $827.56 $1,137.90 $1,026.69 $1,411.70$822.31 $1,130.68 $845.43 $1,162.46 $1,048.85 $1,442.17$857.38 $1,178.90 $881.48 $1,212.04 $1,093.58 $1,503.67$887.71 $1,220.60 $912.66 $1,254.91 $1,132.26 $1,556.86$907.61 $1,247.96 $933.12 $1,283.04 $1,157.65 $1,591.76$932.57 $1,282.28 $958.78 $1,318.32 $1,189.48 $1,635.53$947.73 $1,303.13 $974.37 $1,339.76 $1,208.82 $1,662.13

31609PA0150048 31609PA0150049 31609PA0150050Personal Choice PPO Silver Classic $5,000/$50/$100/90%Personal Choice PPO Silver Secure $4,750/$40/$80/$600Personal Choice PPO Silver HSA-0 $3,500/100%

16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.20 16884.WR-I Rev. 1.208 8 8

Personal Choice Network Personal Choice Network Personal Choice NetworkSilver Silver Silver

$5,000 $4,750 $3,50010% 0% 0%

$50 no ded/$100 no ded $40 no ded/$80 no ded 0% after ded$8,150 $8,150 $6,900

Yes Yes Yes

RATE PAGES









Age Band0-1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco$257.10 $257.10$279.95 $279.95$288.69 $288.69$297.43 $297.43$306.84 $306.84$316.25 $316.25$326.00 $326.00$336.08 $378.09$336.08 $378.09$336.08 $378.09$336.08 $378.09$337.42 $379.60$344.15 $387.16$352.21 $396.24$365.32 $410.98$376.07 $423.08$381.45 $448.20$389.52 $457.68$397.58 $467.16$402.62 $473.08$408.00 $479.40$410.69 $482.56$413.38 $485.72$416.07 $488.88$418.76 $492.04$424.13 $498.36$429.51 $526.15$437.58 $536.03$445.31 $545.50$456.06 $558.67$469.50 $575.14$485.30 $594.49$504.12 $617.55$525.29 $643.48$549.49 $673.13$573.35 $702.36$600.24 $825.33$626.79 $861.84$656.03 $902.04$685.60 $942.70$717.53 $986.60$749.46 $1,030.51$784.07 $1,078.10$819.03 $1,126.16$856.33 $1,177.46$874.82 $1,202.87$912.12 $1,254.17$944.38 $1,298.53$965.56 $1,327.64$992.11 $1,364.15

$1,008.24 $1,386.33


16884.WR-I Rev. 1.208

Personal Choice NetworkSilver

$3,00020%

20% after ded/20% after ded$6,900

Yes

RATE PAGES





Plan Design Summary

RATE PAGES


RATING AREA 812,705 14,784 10,778 22,091 11,234





1

23

4

5

678910111213141516171819202122

232425262728293031323334353637383940414243444546474849

505152

A B C D E F G H I JIf m

Unified Rate Review v5.0

Company Legal Name: QCC Insurance Company, Inc. State: PA

HIOS Issuer ID: 31609 Market: Small Group

Effective Date of Rate Change(s): 1/1/2020

Section I: Experience Period DataExperience Period: 1/1/2018 to 12/31/2018

Total PMPM$441,807,115.40 $526.80

$0.00 $0.00$360,479,052.22 $429.83

$11,856,562.46 $14.14$506,462,338.90 $603.89

838,663

Section II: Projections

Cost Utilization Cost UtilizationInpatient Hospital $88.92 1.042 1.029 1.042 1.029 $102.23Outpatient Hospital $119.20 1.042 1.029 1.042 1.029 $137.04Professional $176.67 1.022 1.029 1.022 1.029 $195.39Other Medical $0.00 1.022 1.029 1.022 1.029 $0.00Capitation $8.75 1.000 0.986 1.000 0.986 $8.51Prescription Drug $133.26 1.020 1.029 0.980 1.029 $141.04Total $526.80 $584.20

1.0001.0131.0001.020

1/1/2020 $603.63

$0.00100.00%

Projected Period Totals1/1/2020 $603.63 $518,580,947.52

$0.00 $0.00-$17.62 -$15,137,412.48

0.00% $0.00$621.25 $533,718,360.00

859,104

Market Level Calculations (Same for all Plans)

Trended EHB Allowed Claims PMPM

Year 1 Trend Year 2 Trend

Allowed ClaimsReinsuranceIncurred Claims in Experience PeriodRisk AdjustmentExperience Period PremiumExperience Period Member Months

Benefit CategoryExperience Period Index

Rate PMPM

OtherAdjusted Trended EHB Allowed Claims PMPM for

Morbidity Adjustment

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.

Projected Member Months

Projected Index Rate forReinsuranceRisk Adjustment Payment/ChargeExchange User FeesMarket Adjusted Index Rate

Applied Credibility %Manual EHB Allowed Claims PMPM

Demographic ShiftPlan Design Changes

1 of 3

1

2

3

4567891011

1213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656667686970717273747576777879808182

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE AF AG AH AI AJ AK AL AM AN

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: QCC Insurance Company, Inc. State: PA To validate, select the Validate button or Ctrl + Shift + I.

HIOS Issuer ID: 31609 Market: Small Group To finalize, select the Finalize button or Ctrl + Shift + F.

Effective Date of Rate Change(s): 1/1/2020

Field # Section I: General Product and Plan Information1.1 Product Name Personal Choice EPO Small Group1.2 Product ID 31609PA017

1.3 Plan Name

Personal Choice PPO Platinum

Preferred $10/$20/$150



Personal Choice PPO Gold Preferred

$35/$70/$600

Personal Choice PPO Gold Classic

$1,000/$15/$30/80%

Personal Choice PPO Silver Classic

$2,500/$30/$60/80%

Personal Choice PPO Platinum HSA-

50 $1,600/100%

Personal Choice PPO Gold HSA-25

$2,400/100%


$2,650/70%

Personal Choice PPO Silver HSA-0

$2,100/70%

Personal Choice PPO Bronze HSA-0

$5,200/50%


$6,550/100%


$2,000/$40/$80/100%


$3,300/$40/$80/100%

Personal Choice PPO Silver Secure

$3,000/$30/$60/$600





Personal Choice PPO Gold Preferred

$40/$80/$600


$1,500/$20/$40/80%


$3,750/$30/$60/70%

Personal Choice PPO Platinum HSA-

50 $1,800/100%


$2,400/$25/$50/90%


$2,100/100%


$2,600/80%


$2,100/70%


$3,000/90%


$5,200/50%


$6,900/100%

Personal Choice PPO Platinum HRA-

50 $1,850/100%

Personal Choice PPO Gold HRA-25

$3,400/100%


$3,200/100%


$2,500 $40/$80/100%


$5,000/$50/$100/90%

Personal Choice PPO Silver Secure

$4,750/$40/$80/$600


$3,500/100%

Personal Choice EPO Silver HSA-0

$3,000/80%1.4 Plan ID (Standard Component ID) 31609PA0150001 31609PA0150002 31609PA0150003 31609PA0150004 31609PA0150005 31609PA0150006 31609PA0150007 31609PA0150009 31609PA0150010 31609PA0150012 31609PA0150013 31609PA0150022 31609PA0150023 31609PA0150024 31609PA0150025 31609PA0150026 31609PA0150027 31609PA0150028 31609PA0150029 31609PA0150030 31609PA0150031 31609PA0150032 31609PA0150033 31609PA0150034 31609PA0150035 31609PA0150036 31609PA0150037 31609PA0150038 31609PA0150039 31609PA0150046 31609PA0150047 31609PA0150048 31609PA0150049 31609PA0150050 31609PA01700011.5 Metal Platinum Platinum Gold Gold Silver Platinum Gold Gold Silver Bronze Bronze Gold Silver Silver Platinum Platinum Gold Gold Silver Platinum Gold Gold Gold Silver Silver Bronze Bronze Platinum Gold Silver Gold Silver Silver Silver Silver1.6 AV Metal Value 0.896 0.883 0.806 0.806 0.717 0.895 0.794 0.808 0.683 0.620 0.612 0.802 0.699 0.720 0.901 0.883 0.816 0.796 0.719 0.900 0.793 0.786 0.785 0.710 0.711 0.628 0.621 0.882 0.816 0.707 0.804 0.716 0.719 0.717 0.6951.7 Plan Category Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Terminated Renewing Terminated Renewing Renewing Renewing Renewing Renewing1.8 Plan Type PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO EPO1.9 Exchange Plan? No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No

1.10 Effective Date of Proposed Rates 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/20201.11 Cumulative Rate Change % (over 12 mos prior) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 12.56% 12.11% 9.64% 10.52% 11.15% 10.47% 11.18% 11.75% 12.88% 12.44% 11.46% 12.46% 13.16% 0.00% 11.69% 0.00% 12.88% 10.55% 9.11% 12.03% 12.43%1.12 Product Rate Increase % 12.43%1.13 Submission Level Rate Increase %

Worksheet 1 Totals Section II: Experience Period and Current Plan Level Information2.1 Plan ID (Standard Component ID) Total 31609PA0150001 31609PA0150002 31609PA0150003 31609PA0150004 31609PA0150005 31609PA0150006 31609PA0150007 31609PA0150009 31609PA0150010 31609PA0150012 31609PA0150013 31609PA0150022 31609PA0150023 31609PA0150024 31609PA0150025 31609PA0150026 31609PA0150027 31609PA0150028 31609PA0150029 31609PA0150030 31609PA0150031 31609PA0150032 31609PA0150033 31609PA0150034 31609PA0150035 31609PA0150036 31609PA0150037 31609PA0150038 31609PA0150039 31609PA0150046 31609PA0150047 31609PA0150048 31609PA0150049 31609PA0150050 31609PA0170001

$441,807,115 2.2 Allowed Claims $441,807,115 $285,095 $85,841 $135,434 $8,629 $8,299 -$4 $96,099 $161 $535 $3,832 -$39 $30,752 $10 $9,923 $59,167,646 $97,962,815 $74,947,184 $10,336,055 $11,019,567 $8,857,424 $22,172,644 $14,572,640 $462,208 $6,702,669 $12,634,472 $32,099,924 $21,829,050 $113,377 $5,500,319 $1,425 $18,630,282 $6,728,062 $12,038,117 $24,129,430 $1,237,235$0 2.3 Reinsurance $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2.4 Member Cost Sharing $81,328,063 $19,085 $2,701 $79,506 $2,625 $3,370 $0 $7,419 $225 $468 $2,117 $0 $7,122 $22 $4,340 $5,808,657 $9,094,421 $12,012,316 $2,072,385 $2,978,629 $1,293,019 $4,292,422 $2,756,907 $155,733 $1,905,661 $3,525,293 $11,595,307 $8,098,254 $9,981 $1,318,338 $1,396 $3,149,777 $1,376,984 $2,603,718 $6,682,849 $467,0172.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$360,479,052 2.6 Incurred Claims $360,479,052 $266,010 $83,140 $55,928 $6,005 $4,929 -$4 $88,680 -$64 $67 $1,715 -$39 $23,629 -$12 $5,583 $53,358,989 $88,868,395 $62,934,868 $8,263,671 $8,040,937 $7,564,405 $17,880,222 $11,815,733 $306,475 $4,797,008 $9,109,179 $20,504,618 $13,730,796 $103,396 $4,181,981 $29 $15,480,504 $5,351,079 $9,434,398 $17,446,582 $770,219$11,856,562 2.7 Risk Adjustment Transfer Amount $11,856,562 $96,614 $31,164 -$55,290 $3,025 -$13,825 -$339 -$19,459 -$5,803 -$7,283 -$37,235 -$2,678 -$8,955 -$1,134 -$26,138 $6,559,638 $6,880,213 -$5,107,658 -$147,103 -$1,366,838 $812,677 $876,698 $2,110,221 -$217,743 -$550,913 -$1,033,580 $1,994,615 $51,028 -$23,103 $398,184 -$6,560 -$575,535 -$1,000,262 -$2,519,664 $4,979,655 -$210,073

$506,462,339 2.8 Premium $506,462,339 $269,072 $44,301 $124,918 $10,480 $27,939 $531 $52,074 $8,741 $19,512 $47,148 $3,403 $42,720 $6,589 $43,950 $75,575,416 $112,751,106 $96,031,483 $12,549,954 $13,298,726 $9,358,277 $23,454,617 $15,197,688 $608,672 $6,863,441 $14,979,545 $29,499,748 $21,726,580 $83,130 $6,379,348 $14,081 $21,783,703 $7,018,710 $12,723,737 $24,304,395 $1,558,603838,663 2.9 Experience Period Member Months 838,663 345 59 232 21 61 1 92 18 34 115 11 66 12 120 94,402 150,740 158,359 20,198 26,607 13,936 39,198 23,104 1,142 13,588 25,795 78,073 52,746 91 10,534 19 36,269 15,097 28,493 45,353 3,732

2.10 Current Enrollment 71,592 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,498 12,004 13,795 1,741 2,451 1,030 1,240 2,023 106 1,064 1,848 7,585 4,128 0 793 0 3,627 1,406 2,724 5,833 6962.11 Current Premium PMPM $604.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $818.76 $763.25 $617.99 $624.20 $492.13 $682.06 $589.06 $670.90 $536.25 $511.95 $595.12 $380.85 $427.39 $0.00 $631.69 $0.00 $610.20 $440.33 $445.61 $545.19 $446.972.12 Loss Ratio 69.55% 72.74% 110.17% 80.32% 44.46% 34.92% -1.85% 271.90% -2.18% 0.55% 17.30% -5.39% 69.98% -0.22% 31.34% 64.96% 74.29% 69.22% 66.63% 67.39% 74.37% 73.49% 68.27% 78.40% 75.99% 65.32% 65.11% 63.05% 172.25% 61.70% 0.38% 72.99% 88.91% 92.46% 59.58% 57.12%

Per Member Per Month2.13 Allowed Claims $526.80 $826.36 $1,454.93 $583.77 $410.91 $136.05 -$3.55 $1,044.56 $8.97 $15.74 $33.33 -$3.55 $465.93 $0.82 $82.70 $626.76 $649.88 $473.27 $511.74 $414.16 $635.58 $565.66 $630.74 $404.74 $493.28 $489.80 $411.15 $413.85 $1,245.91 $522.15 $74.99 $513.67 $445.66 $422.49 $532.04 $331.522.14 Reinsurance $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.002.15 Member Cost Sharing $96.97 $55.32 $45.78 $342.70 $124.98 $55.24 $0.00 $80.64 $12.53 $13.78 $18.41 $0.00 $107.91 $1.81 $36.17 $61.53 $60.33 $75.85 $102.60 $111.95 $92.78 $109.51 $119.33 $136.37 $140.25 $136.67 $148.52 $153.53 $109.68 $125.15 $73.48 $86.84 $91.21 $91.38 $147.35 $125.142.16 Cost Sharing Reduction $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.002.17 Incurred Claims $429.83 $771.04 $1,409.15 $241.07 $285.94 $80.81 -$3.55 $963.92 -$3.55 $1.97 $14.92 -$3.55 $358.02 -$0.98 $46.53 $565.23 $589.55 $397.42 $409.13 $302.21 $542.80 $456.15 $511.42 $268.37 $353.03 $353.14 $262.63 $260.32 $1,136.22 $397.00 $1.50 $426.82 $354.45 $331.11 $384.68 $206.382.18 Risk Adjustment Transfer Amount $14.14 $280.04 $528.20 -$238.32 $144.04 -$226.63 -$338.89 -$211.51 -$322.37 -$214.21 -$323.78 -$243.42 -$135.67 -$94.47 -$217.81 $69.49 $45.64 -$32.25 -$7.28 -$51.37 $58.31 $22.37 $91.34 -$190.67 -$40.54 -$40.07 $25.55 $0.97 -$253.88 $37.80 -$345.25 -$15.87 -$66.26 -$88.43 $109.80 -$56.292.19 Premium $603.89 $779.92 $750.87 $538.44 $499.04 $458.02 $531.17 $566.02 $485.61 $573.88 $409.98 $309.36 $647.27 $549.09 $366.25 $800.57 $747.98 $606.42 $621.35 $499.82 $671.52 $598.36 $657.79 $532.99 $505.11 $580.72 $377.85 $411.91 $913.51 $605.60 $741.10 $600.61 $464.91 $446.56 $535.89 $417.63

Section III: Plan Adjustment Factors3.1 Plan ID (Standard Component ID) 31609PA0150001 31609PA0150002 31609PA0150003 31609PA0150004 31609PA0150005 31609PA0150006 31609PA0150007 31609PA0150009 31609PA0150010 31609PA0150012 31609PA0150013 31609PA0150022 31609PA0150023 31609PA0150024 31609PA0150025 31609PA0150026 31609PA0150027 31609PA0150028 31609PA0150029 31609PA0150030 31609PA0150031 31609PA0150032 31609PA0150033 31609PA0150034 31609PA0150035 31609PA0150036 31609PA0150037 31609PA0150038 31609PA0150039 31609PA0150046 31609PA0150047 31609PA0150048 31609PA0150049 31609PA0150050 31609PA01700013.2 Market Adjusted Index Rate3.3 AV and Cost Sharing Design of Plan 1.0644 1.0177 0.8306 0.8415 0.6657 0.9177 0.7596 0.6344 0.6437 0.4843 0.5182 0.8410 0.5732 0.7671 1.0864 1.0341 0.8259 0.8110 0.6626 0.9223 0.7690 0.8945 0.6983 0.6577 0.7240 0.4955 0.5335 0.0000 0.8122 0.7139 0.8102 0.5713 0.5873 0.7286 0.63973.4 Provider Network Adjustment 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0005 1.0005 1.0005 1.0005 1.0005 1.0005 1.0005 1.0005 1.0005 1.0005 1.0005 1.0005 1.0005 1.0000 1.0005 1.0000 1.0005 1.0005 1.0005 1.0005 0.95053.5 Benefits in Addition to EHB 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0095 1.0095 1.0095 1.0095 1.0095 1.0095 1.0095 1.0095 1.0095 1.0095 1.0095 1.0095 1.0095 1.0000 1.0095 1.0000 1.0095 1.0095 1.0095 1.0095 1.0095

Administrative Costs3.6 Administrative Expense 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65% 14.65%3.7 Taxes and Fees 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87% 5.87%3.8 Profit & Risk Load 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%3.9 Catastrophic Adjustment 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

3.10 Plan Adjusted Index Rate $853.46 $816.01 $665.99 $674.73 $533.77 $735.83 $609.06 $508.67 $516.13 $388.32 $415.50 $674.33 $459.60 $615.08 $879.81 $837.46 $668.85 $656.78 $536.60 $746.92 $622.77 $724.40 $565.51 $532.63 $586.33 $401.28 $432.05 $0.00 $657.75 $572.42 $656.13 $462.66 $475.62 $590.05 $492.17

3.11 Age Calibration Factor 0.66123.12 Geographic Calibration Factor 1.00003.13 Tobacco Calibration Factor 0.98723.14 Calibrated Plan Adjusted Index Rate $557.08 $532.64 $434.72 $440.42 $348.41 $480.30 $397.56 $332.03 $336.90 $253.47 $271.21 $440.16 $300.00 $401.48 $574.29 $546.64 $436.58 $428.71 $350.26 $487.54 $406.50 $472.84 $369.13 $347.67 $382.72 $261.93 $282.02 $0.00 $429.34 $373.64 $428.28 $302.00 $310.45 $385.15 $321.25

Section IV: Projected Plan Level Information4.1 Plan ID (Standard Component ID) Total 31609PA0150001 31609PA0150002 31609PA0150003 31609PA0150004 31609PA0150005 31609PA0150006 31609PA0150007 31609PA0150009 31609PA0150010 31609PA0150012 31609PA0150013 31609PA0150022 31609PA0150023 31609PA0150024 31609PA0150025 31609PA0150026 31609PA0150027 31609PA0150028 31609PA0150029 31609PA0150030 31609PA0150031 31609PA0150032 31609PA0150033 31609PA0150034 31609PA0150035 31609PA0150036 31609PA0150037 31609PA0150038 31609PA0150039 31609PA0150046 31609PA0150047 31609PA0150048 31609PA0150049 31609PA0150050 31609PA01700014.2 Allowed Claims $538,816,703 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $66,868,697 $103,186,978 $102,585,519 $13,997,056 $17,042,777 $8,048,959 $8,944,748 $16,909,700 $638,595 $7,060,072 $13,599,730 $46,414,624 $27,030,267 $0 $6,095,163 $0 $27,787,010 $8,307,479 $16,875,852 $42,925,984 $4,497,4944.3 Reinsurance $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $04.4 Member Cost Sharing $97,834,360 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $4,323,943 $7,875,640 $15,100,474 $3,156,479 $4,573,166 $754,683 $1,623,159 $3,014,999 $70,245 $1,686,900 $3,326,374 $17,559,586 $10,121,213 $0 $1,149,583 $0 $5,223,958 $2,140,256 $4,591,864 $10,292,112 $1,249,7244.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $04.6 Incurred Claims $440,982,342 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $62,544,754 $95,311,338 $87,485,046 $10,840,577 $12,469,611 $7,294,276 $7,321,590 $13,894,700 $568,350 $5,373,171 $10,273,356 $28,855,037 $16,909,054 $0 $4,945,580 $0 $22,563,052 $6,167,223 $12,283,987 $32,633,872 $3,247,7704.7 Risk Adjustment Transfer Amount -$12,216,459 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 -$1,279,459 -$2,048,363 -$2,353,979 -$297,084 -$418,239 -$175,759 -$211,594 -$345,205 -$18,088 -$181,561 -$315,343 -$1,294,304 -$704,402 $0 -$135,318 $0 -$618,911 -$239,920 -$464,823 -$995,343 -$118,7654.8 Premium $569,123,266 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $80,719,047 $123,006,966 $112,906,505 $13,990,638 $16,093,038 $9,413,851 $9,449,102 $17,932,231 $733,501 $6,934,511 $13,258,594 $37,239,752 $21,822,497 $0 $6,382,670 $0 $29,119,438 $7,959,298 $15,853,476 $42,116,643 $4,191,5094.9 Projected Member Months 859,104 0 0 0 0 0 0 0 0 0 0 0 0 0 0 89,976 144,048 165,540 20,892 29,412 12,360 14,880 24,276 1,272 12,768 22,176 91,020 49,536 0 9,516 0 43,524 16,872 32,688 69,996 8,352

4.10 Loss Ratio 79.18% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 78.73% 78.80% 79.13% 79.17% 79.55% 78.96% 79.26% 79.01% 79.44% 79.57% 79.37% 80.27% 80.07% #DIV/0! 79.16% #DIV/0! 79.17% 79.89% 79.82% 79.36% 79.74%Per Member Per Month

4.11 Allowed Claims $627.18 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $743.18 $716.34 $619.70 $669.97 $579.45 $651.21 $601.13 $696.56 $502.04 $552.95 $613.26 $509.94 $545.67 #DIV/0! $640.52 #DIV/0! $638.43 $492.38 $516.27 $613.26 $538.494.12 Reinsurance $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.004.13 Member Cost Sharing $113.88 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $48.06 $54.67 $91.22 $151.09 $155.49 $61.06 $109.08 $124.20 $55.22 $132.12 $150.00 $192.92 $204.32 #DIV/0! $120.81 #DIV/0! $120.02 $126.85 $140.48 $147.04 $149.634.14 Cost Sharing Reduction $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.004.15 Incurred Claims $513.30 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $695.13 $661.66 $528.48 $518.89 $423.96 $590.15 $492.04 $572.36 $446.82 $420.83 $463.26 $317.02 $341.35 #DIV/0! $519.71 #DIV/0! $518.40 $365.53 $375.80 $466.22 $388.864.16 Risk Adjustment Transfer Amount -$14.22 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 -$14.22 #DIV/0! -$14.22 #DIV/0! -$14.22 -$14.22 -$14.22 -$14.22 -$14.224.17 Premium $662.46 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $897.12 $853.93 $682.05 $669.66 $547.16 $761.64 $635.02 $738.68 $576.65 $543.12 $597.88 $409.14 $440.54 #DIV/0! $670.73 #DIV/0! $669.04 $471.75 $484.99 $601.70 $501.86

0.66121.00000.9872

$621.25

Product/Plan Level Calculations

Personal Choice PPO Small Group31609PA015

11.54%11.54%

2 of 3

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A BRating Area Data CollectionIf 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.

Rating Area Rating FactorRating Area 8 1.0000

3 of 3

URRT Part II – Consumer Friendly Justification

INAC-131927133 Consumer Friendly Justification QCC Small Group 1Q2020 May 21, 2019

Scope and Range of the Rate Increase:

QCC Insurance Company ("QCC”) is revising premium rates for the Pennsylvania Small Group ACA compliant products, effective from January 1, 2020. The proposed revisions to each plan are shown on the second page of this exhibit. About 72,000 members will be affected.

Financial Experience of the Product:

QCC is required by federal law to pay out a minimum of 80% percent of premium dollars for medical claims—this is referred to as the minimum Medical Loss Ratio (MLR). The rate action proposed in this filing is expected to achieve a Medical Loss Ratio of greater than 80%.

Changes in Taxes and Fees:

The Federal government suspended the Health Insurance Providers Fee for premiums due in 2019, but will be re-implementing it for premiums due in 2020. This increases 2020 premium rates.

Changes in Medical Service Costs:

Premium rates for health care insurance are increasing as the cost of health care service rise. Health care service costs increase as health care providers increase their fees, members use more health care services and supplies, and the types of health care services and supplies change, among other factors. We are projecting that claims will increase by 6.2% in 2020. Nearly half of the change in health care service costs is driven by changes to health care provider fees.

Changes in Benefits:

Some plan benefits are mandated by federal and state law. Benefit changes for some plans were also made. All changes in benefits are in compliance with the uniform modifications rules stipulated by the Federal government.

Administrative Costs:

The premium rates presented in this filing include a 2% contribution to reserves. Furthermore, the Affordable Care Act (ACA) imposes taxes and other levies.

URRT Part II – Consumer Friendly Justification

INAC-131927133 2 Consumer Friendly Justification

QCC Small Group 1Q2020 May 21, 2019

HIOS ID Plan Name 1Q % Change 2Q % Change 3Q % Change 4Q % Change

31609PA0150025 Personal Choice PPO Platinum Preferred $10/$20/$150 6.3% 14.4% 18.1% 18.2%

31609PA0150026 Personal Choice PPO Platinum Preferred $20/$40/$150 5.9% 14.0% 17.6% 17.7%

31609PA0150027 Personal Choice PPO Gold Preferred $35/$70/$600 3.6% 11.5% 15.0% 15.1%

31609PA0150028 Personal Choice PPO Gold Classic $1,500/$15/$30/80% 4.4% 12.4% 15.9% 16.0%

31609PA0150029 Personal Choice PPO Silver Classic $3,250/$30/$60/70% 5.0% 13.0% 16.6% 16.7%

31609PA0150030 Personal Choice PPO Platinum HSA-50 $1,600/100% 4.3% 12.3% 15.9% 16.0%

31609PA0150031 Personal Choice PPO Gold HSA-25 $2,400/90% 5.0% 13.0% 16.6% 16.7%



31609PA0150034 Personal Choice PPO Silver HSA-0 $2,100/70% 6.2% 14.3% 17.9% 18.0%


31609PA0150036 Personal Choice PPO Bronze HSA-0 $5,200/50% 6.2% 14.3% 18.0% 18.1%

31609PA0150037 Personal Choice PPO Bronze HSA-0 $6,750/100% 6.9% 15.1% 18.7% 18.8%

31609PA0150039 Personal Choice PPO Gold HRA-25 $3,200/100% 5.5% 13.6% 17.2% 17.3%

31609PA0150047 Personal Choice PPO Gold Classic $2,500 $40/$80/100% 6.6% 14.8% 18.4% 18.5%

31609PA0150048 Personal Choice PPO Silver Classic $4,750/$50/$100/90% 4.4% 12.4% 16.0% 16.0%

31609PA0150049 Personal Choice PPO Silver Secure $4,500/$35/$70/$600 3.1% 10.9% 14.5% 14.5%


31609PA0170001 Personal Choice EPO Silver HSA-0 $3,000/80% 6.2% 14.3% 17.9% 18.0%

INAC-131927133 1 URRT Part III QCC Small Group 1Q2020 May 21, 2019 Revised June 25, 2019

GENERAL OVERVIEW

PURPOSES

This Actuarial Memorandum is provided along with the Unified Rate Review Template (URRT) to provide

certain information to support the gross premium for the single risk pool for small group market health

care insurance underwritten by QCC Insurance Company, Inc. in the Commonwealth of Pennsylvania. It

is provided as a component of an application for certification as a Qualified Health Plan and a state rate

filing. This submission may not be appropriate for other purposes.

GENERAL INFORMATION

COMPANY IDENTIFYING INFORMATION

Company Legal Name: QCC Insurance Company, Inc. (“QCC”)

State: Pennsylvania

HIOS Issuer ID (5-digit): 31609

Market: Small Group

Effective Date(s): 1/1/2020-3/31/2020, 4/1/2020 – 6/30/2020, 7/1/2020 – 9/30/2020,

10/1/2020 – 12/31/2020

Worksheet 1 of the accompanying URRT contains experience period data and development of the

projected Single Risk Pool Gross Premium Average Rate PMPM for the small group market for QCC.

Worksheet 2 contains experience period data and projections by product for the single risk pool for the

same entities.

COMPANY CONTACT INFORMATION

Primary Contact Name: XXXXXXXXXXXXX

Primary Contact Telephone Number: XXXXXXXXXXXXX

Primary Contact Email Address: XXXXXXXXXXXXX

PROPOSED RATE INCREASE

The changes to the single risk pool gross premium average rate per member per month (PMPM) from

calendar year 2018 to calendar year 2020 were incorporated into the pricing and reflected in the Unified

Rate Review Template. The changes are driven by factors including: changes in market-wide population

risk morbidity and covered services, increasing unit costs for medical services, increasing utilization of

medical services, increasing fees and taxes imposed by the federal government, anticipated costs to

administer the plan, and anticipated revenue or payments due to market-wide risk adjustment.


The weighted average increase across QCC plans based on projected membership, inclusive of the

impact of benefit and cost sharing changes, is 11.9%. The minimum increase is 9.4% and the maximum

increase is 13.5%.

WORKSHEET 1: MARKET EXPERIENCE

SECTION I: EXPERIENCE PERIOD DATA

SINGLE RISK POOL

The single risk pool reflects all covered lives for every small group non-grandfathered product and plan combination for KHPE in the state of Pennsylvania. It is established according to the Single Risk Pool requirements in 45 CFR § 156.80(d).

PAID THROUGH DATE

Experience period premium, claims, and member months are obtained from the company’s internal

data warehouse. The claims data is collected for incurred dates from January through December 2018

and paid through February 2019. Earned premiums and member months are for January through

December 2018. The data are for all direct-written small group business of KHPE in the Commonwealth

of Pennsylvania.

PREMIUMS IN EXPERIENCE PERIOD

Earned Premiums in the Experience Period are developed by summing the earned premium reported in

the company’s internal data warehouse.

ALLOWED AND INCURRED CLAIMS INCURRED DURING THE EXPERIENCE PERIOD

Paid-to-Date and Incurred Claims, and Member Months

Insurer fee-for-service claims expenses and member liabilities for dates of service in January 2018

through December 2018 and paid through February 2019 are sourced from the IBCFOC’s internal data

warehouse. The claims and member liabilities are completed with incurred but not reported (IBNR)

adjustments to develop ultimate incurred insurer fee-for-service claims expenses and member liabilities

for the January through December 2018 period. Capitation amounts are also sourced from the internal

data warehouse for the January through December 2018 period but they are not adjusted for IBNR.

Allowed Claims

Allowed claims are determined by separately obtaining paid-to-date fee-for-service claims and member

cost-sharing amounts, applying claim lag factors to those amounts to estimate ultimate incurred fee-for-

service claims and member-sharing amounts and adding them together with capitation amounts.


Allowed claims do not include ineligible claims, payments for services other than medical care provided,

recovery payments related to internal large claim pooling mechanisms, or active live reserves.

IBNR Development

Medical fee for service incurred but not reported (IBNR) claims are modeled through the use of standard

claim lag methodologies. A range of results is developed, and a provision for adverse deviation is

applied. The provision for adverse deviation is dependent on many factors such as stability, size, product

mix, etc.

The completion factors are developed annually in the 2Q – 3Q period. We do not believe our IBNR is

unusually high or unusually low for incurred 2018 paid through February 2019.

Experience Period Index Rate

The Index Rate of Experience Period is estimated by removing cost and utilization trend from the Index

Rate for Projection Period.

SECTION II: PROJECTIONS

BENEFIT CATEGORIES

Experience Period Index Rate PMPM Data is provided in Section II. The data is provided by benefit

category using a standardized indicator from the internal data warehouse that assigns each claim line to

a category based on the type of provider and the location of the service.

PROJECTION FACTORS

The estimated incurred claims experience on an allowed basis for January 2018 through December 2018

is projected to the future rating period by several factors.

Morbidity Adjustment

Experience period allowed claims are adjusted to account for differences in the average morbidity of the

single risk pool population underlying the experience and the anticipated population in the projection

period. This adjustment reflects changes in the small group market-wide morbidity.

Demographic Shift

This factor reflects the projected change in the average age, rating area, and tobacco utilization of the

single risk pool.

Plan Design Changes

This factor reflects any changes in EHB allowed claims due to plan design changes.


Other Changes

This factor reflects changes in cost related to items other than changes in Morbidity, Demographic Shift,

or Plan Design.

Trend Factors

a. Annualized Cost Trend

Annual cost trend reflects changes in costs of medical treatment due to medical inflation and changes in

the distribution of services across network providers. The trend value is developed by reviewing

historical medical costs for the single risk pool and adjusting them for anticipated future provider

contracting reimbursement levels. The data is normalized for changes in age, benefit changes during the

experience period, changes to provider contracts, and prescription drug formulary, and new drugs

brought to market.

b. Annualized Utilization Trend

Annual utilization trend reflects the change in the number of units per 1,000 members for a fixed level

of illness burden and includes changes due to the mix and intensity of services provided and changes

related to shifts in product mix. It also includes effects of selection, if any, since this cannot be reflected

in the relative cost of the various products and plans offered.

c. Quarterly Premium Trend

Rates for second, third and fourth quarters increase by 1.5% each quarter.

CREDIBILITY MANUAL RATE DEVELOPMENT

The experience period claims for the single risk pool are determined to be fully credible; therefore no

credibility adjustment is required.

RISK ADJUSTMENT AND REINSURANCE

Projected Risk Adjustment PMPM

Projected Risk Adjustment is accounted for in Projected Incurred Claims before ACA Reinsurance and

Risk Adjustment to reflect anticipated risk adjustment transfer amounts for the projection period. The

amount reflects the projected morbidity for the single risk pool.

The estimated risk adjustment revenue for all of the plans in the risk pool is developed using the

following methodology. We recognize that the HHS payment transfer formula implies that the projected

incurred claims based solely on the experience period single risk pool claims need to be adjusted by the

ratio of the current statewide market’s risk relative to allowable rating factor (ARF) for age compared to

the single risk pool’s risk relative to ARF presented during the experience period. This adjustment,


together with the assumed future changes in population risk morbidity, results in the issuer’s pricing

being consistent with the anticipated morbidity level of the future statewide market.

The anticipated risk adjustment transfer revenue is allocated proportionally based on plan premium.

The Projected Risk Adjustment is subtracted from Projected Incurred Claims before ACA Risk Adjustment

to reflect anticipated receipt of risk adjustment transfer amounts for the projection period.

When the projected risk adjustment amounts for KHPE and QCC are combined, the result is consistent

with the projection made in our submission. We also considered preliminary 2018 risk transfer results.

MARKET ADJUSTED INDEX RATE

The template calculates a MAIR by subtracting the amounts entered for reinsurance and risk adjustment

and dividing by 1 minus the exchange user fee percentage. The MAIR calculation flows into Worksheet

2.

The Market Adjusted Index rate is calculated as the Index Rate adjusted for all allowable market-wide

modifiers defined in the market rating rules: federal reinsurance program adjustment, risk adjustment

and exchange user fees. The Market Adjusted Index Rate reflects the average demographic

characteristics of the single risk pool.

WORKSHEET 2: PRODUCT-PLAN DATA COLLECTION

SECTION I: GENERAL PRODUCT AND PLAN INFORMATION

All products and plans included in the single risk pool are shown in Worksheet 2.

AV METAL VALUES

The AV Metal Values included in Worksheet 2 of the URRT were valued using the AV Calculator, where

possible, otherwise the AV Metal Values were developed under an alternate methodology. Actuarial

certifications required by 45 CFR Part 156, §156.135 are provided in a separate document.

SECTION II: EXPERIENCE PERIOD AND CURRENT PLAN LEVEL INFORMATION

Experience Period data is shown for each plan included in the single risk pool.

SECTION III: PLAN ADJUSTMENT FACTORS

The MAIR is adjusted for each plan based on its plan design, provider network, and non-EHBs.

Administrative costs are added to calculate the Plan Adjusted Index Rate. The Plan Adjusted Index Rate


is multiplied by the Age Calibration Factor, Geographic Calibration Factor, and Tobacco Calibration

Factor to calculate the Calibrated Plan Adjusted Index Rate.

PLAN ADJUSTED INDEX RATE

The Plan Adjusted Index Rate is calculated as the issuer Market Adjusted Index Rate adjusted for all

allowable plan level modifiers defined in the market rating rule. These include actuarial value and cost

sharing adjustment, provider network, delivery system and utilization management adjustment,

adjustment for benefits in addition to the EHBs, impact of specific eligibility categories for the

catastrophic plan and administrative costs.

NON-BENEFIT EXPENSES AND PROFIT & RISK

Administrative Expense Load

An Administrative Expense Load is applied to Projected Incurred Claims to reflect expenses related to

quality improvement and fraud detection/recovery and other expenses of operating a business, broker

commissions, and premium payment processing fees.

Profit & Risk Load/Contribution to Surplus

A Profit & Risk Load/Contribution to Surplus for the single risk pool is applied to Projected Incurred

Claims for the projection period, if applicable.

Taxes and Fees

A Taxes & Fees load is applied to Projected Incurred Claims to pass through fees and taxes levied by the

federal and state governments.

CALIBRATION

The plan adjusted index rate is projected for all products using the same anticipated age distribution

and the mandated age curve. Therefore the consumer adjusted premium rate is the plan adjusted index

rate divided by the average age, geographic and tobacco factors for the expected distribution. The

average age of the combined small group risk pool population is 36.

The Average Age factor is the reciprocal of the weighted average age factor based on the projected

membership. The Tobacco Factor is calculated as the reciprocal of the projected average factor for

tobacco users multiplied by the projected tobacco use prevalence.

There is only one geographic rating area for this filing. The geographic rating area factor for this filing is

1.0.


Small differences result between the Calibrated Plan Adjusted Index rates and the Age 21 non-tobacco

rates in the Rate Template due to rounding restrictions required in the URRT Part 1.

When rounded to the nearest dollar, the Calibrated Plan Adjusted Index Rates match the Age 21 non-

tobacco rates in the Rate Template as required in the DIT.

MEMBERSHIP PROJECTIONS

Enrollment is projected based on current and anticipated enrollment by plan. Items impacting these

projections include changes in the size of the market due to guarantee issue requirements and the

individual mandate changes. The enrollment is our February 2019 enrollment.

LOSS RATIO

The loss ratio calculated in Section IV is generated within the template and is not based on the MLR

formula. The projected loss ratio for the single risk pool is estimated to exceed 80% reflecting premium

adjustments permitted by the federal MLR calculation.

INDEX RATE

The Index Rate is defined as the EHB portion of projected allowed claims divided by all projected single risk pool lives. The Index Rate is the same value for all non-grandfathered plans for KHPE Small Group Plans in Pennsylvania. The Index Rate reflects the twelve month projection for calendar year 2020. It has been developed following the specifications of 45 CFR § 156.80(d)(1).

TERMINATED PLANS

No plans are being terminated during 2020.

WORKSHEET 3: RATING AREAS

There are nine rating areas in Pennsylvania. These plans are offered only in Rating Area 8, which

consists of Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.


ACTUARIAL CERTIFICATION

I, XXXXXXXXXXXXX, am Director & Actuary of Commercial Markets for the Independence Blue Cross Family of Companies. I am a member of the Society of Actuaries and the American Academy of Actuaries in good standing with the education and experience necessary to perform the work necessary and meet the Qualification Standards of the American Academy of Actuaries to render the qualified actuarial opinion contained herein. The developed rates and memorandum have been prepared in conformity with appropriate Actuarial Standards of Practice and the Academy’s Code of Professional Conduct. The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the premium rates and allowable rating factors. Rather, it represents information required by Federal regulation to be provided in support of the review of rate increases, for certification of Qualified Health Plans for Federally-facilitated Exchanges, and for certification that the Index Rate is developed in accordance with federal regulation and used consistently and only adjusted by the allowable modifiers.

I hereby certify that, to the best of my knowledge and judgment, the following:

▪ The projected index rate is:

—In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.80 and 147.102);

—Developed in compliance with applicable Actuarial Standards of Practice;

—Reasonable in relation to the benefits provided and the population anticipated to be covered; and

—Neither excessive nor deficient.

▪ The index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2) were used to generate plan level rates.

▪ Geographic rating factors reflect only differences in the costs of delivery of and do not include differences for population morbidity by geographic area.

▪ The percent of total premium that represents EHB included in the Part I Unified Rate Review Template, Worksheet 2, Sections III and IV, was calculated in accordance with actuarial standards of practice.

▪ The AV Calculator was used to determine the AV Metal Values shown in Worksheet 2 of the Part I Unified Rate Review Template for all plans, unless an alternate methodology was required. When an alternate methodology was used to calculate the AV Metal Value a copy of the actuarial certification required by 45 CFR Part 156, §156.135 was included.

XXXXXXXXXXXXX

May 21, 2019

2020 Rates Table Template v9.0 All fields with an asterisk ( * ) are required. To validate press Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.

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 B1 through B5.If you are in a community rating state, select Family-Tier Rates under Rating Method and fill in all columns.

If you are not in a community rating state, select Age-Based Rates under Rating Method and provide an Individual Rate for every age band.

If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use.

To add a new sheet, press the Add Sheet button, or Ctrl + Shift + H. All plans must have the same dates on a sheet.

HIOS Issuer ID* 31609Federal TIN* 23-2184623

Rate Effective Date* 1/1/2020Rate Expiration Date* 3/31/2020

Rating Method* Age-Based Rates

Plan ID* Rating Area ID* Tobacco* Age* Individual Rate* Individual Tobacco Rate*

Required:Enter the 14-character Plan ID

Required:Select the Rating Area ID

Required:Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a plan

Required:Select the age of a subscriber eligible for the

rate

Required:Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

Required:Enter the rate of an Individual tobacco enrollee

on a plan

31609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 439.32 439.3231609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 15 478.37 478.3731609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 16 493.30 493.3031609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 17 508.23 508.2331609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 18 524.31 524.3131609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 19 540.39 540.3931609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 20 557.04 557.0431609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 21 574.27 646.0531609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 22 574.27 646.0531609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 23 574.27 646.0531609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 24 574.27 646.0531609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 25 576.57 648.6431609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 26 588.05 661.5631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 27 601.83 677.0631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 28 624.23 702.2631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 29 642.61 722.9331609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 30 651.80 765.8631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 31 665.58 782.0631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 32 679.36 798.2531609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 33 687.98 808.3731609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 34 697.16 819.1731609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 35 701.76 824.5731609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 36 706.35 829.9631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 37 710.95 835.3631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 38 715.54 840.7631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 39 724.73 851.5631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 40 733.92 899.0531609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 41 747.70 915.9331609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 42 760.91 932.1131609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 43 779.28 954.6231609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 44 802.26 982.7631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 45 829.25 1015.8331609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 46 861.41 1055.2231609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 47 897.58 1099.5431609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 48 938.93 1150.1931609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 49 979.70 1200.1431609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 50 1025.65 1410.2631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 51 1071.01 1472.6431609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 52 1120.98 1541.3431609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 53 1171.51 1610.8331609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 54 1226.07 1685.8431609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 55 1280.62 1760.8631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 56 1339.77 1842.1931609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 57 1399.50 1924.3131609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 58 1463.24 2011.9531609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 59 1494.82 2055.3831609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 60 1558.57 2143.0331609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 61 1613.70 2218.8431609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 62 1649.88 2268.5831609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 63 1695.25 2330.9631609PA0150025 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1722.81 2368.8631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 418.16 418.1631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 15 455.33 455.3331609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 16 469.55 469.5531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 17 483.76 483.7631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 18 499.06 499.0631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 19 514.37 514.3731609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 20 530.22 530.2231609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 21 546.62 614.9531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 22 546.62 614.9531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 23 546.62 614.9531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 24 546.62 614.9531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 25 548.81 617.4131609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 26 559.74 629.7131609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 27 572.86 644.4631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 28 594.18 668.4531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 29 611.67 688.1331609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 30 620.41 728.9931609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 31 633.53 744.4031609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 32 646.65 759.8231609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 33 654.85 769.4531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 34 663.60 779.7331609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 35 667.97 784.8631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 36 672.34 790.0031609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 37 676.72 795.1431609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 38 681.09 800.2831609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 39 689.83 810.5631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 40 698.58 855.7631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 41 711.70 871.8331609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 42 724.27 887.2331609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 43 741.76 908.6631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 44 763.63 935.4431609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 45 789.32 966.9231609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 46 819.93 1004.4131609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 47 854.37 1046.6031609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 48 893.72 1094.8131609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 49 932.53 1142.3531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 50 976.26 1342.3631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 51 1019.45 1401.7431609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 52 1067.00 1467.1331609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 53 1115.10 1533.2731609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 54 1167.03 1604.6731609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 55 1218.96 1676.0731609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 56 1275.26 1753.4931609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 57 1332.11 1831.6631609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 58 1392.79 1915.0831609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 59 1422.85 1956.4231609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 60 1483.53 2039.8531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 61 1536.00 2112.0031609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 62 1570.44 2159.3531609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 63 1613.62 2218.7331609PA0150026 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1639.86 2254.8131609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 334.00 334.0031609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 15 363.69 363.6931609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 16 375.04 375.0431609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 17 386.39 386.3931609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 18 398.62 398.6231609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 19 410.84 410.8431609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 20 423.50 423.5031609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 21 436.60 491.1831609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 22 436.60 491.1831609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 23 436.60 491.1831609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 24 436.60 491.1831609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 25 438.35 493.1431609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 26 447.08 502.9631609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 27 457.56 514.7531609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 28 474.58 533.9131609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 29 488.56 549.6231609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 30 495.54 582.26

31609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 31 506.02 594.5731609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 32 516.50 606.8831609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 33 523.05 614.5831609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 34 530.03 622.7931609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 35 533.53 626.8931609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 36 537.02 631.0031609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 37 540.51 635.1031609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 38 544.00 639.2031609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 39 550.99 647.4131609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 40 557.97 683.5231609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 41 568.45 696.3631609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 42 578.50 708.6631609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 43 592.47 725.7731609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 44 609.93 747.1631609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 45 630.45 772.3031609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 46 654.90 802.2531609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 47 682.41 835.9531609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 48 713.84 874.4631609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 49 744.84 912.4331609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 50 779.77 1072.1831609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 51 814.26 1119.6131609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 52 852.24 1171.8331609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 53 890.66 1224.6631609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 54 932.14 1281.6931609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 55 973.62 1338.7231609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 56 1018.59 1400.5631609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 57 1063.99 1462.9931609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 58 1112.46 1529.6331609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 59 1136.47 1562.6531609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 60 1184.93 1629.2831609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 61 1226.85 1686.9131609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 62 1254.35 1724.7331609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 63 1288.84 1772.1631609PA0150027 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1309.80 1800.9831609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 327.93 327.9331609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 15 357.08 357.0831609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 16 368.23 368.2331609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 17 379.37 379.3731609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 18 391.38 391.3831609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 19 403.38 403.3831609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 20 415.81 415.8131609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 21 428.67 482.2531609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 22 428.67 482.2531609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 23 428.67 482.2531609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 24 428.67 482.2531609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 25 430.38 484.1831609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 26 438.96 493.8331609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 27 449.25 505.4031609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 28 465.96 524.2131609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 29 479.68 539.6431609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 30 486.54 571.6931609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 31 496.83 583.7731609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 32 507.12 595.8631609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 33 513.55 603.4231609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 34 520.41 611.4831609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 35 523.83 615.5131609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 36 527.26 619.5431609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 37 530.69 623.5631609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 38 534.12 627.5931609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 39 540.98 635.6531609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 40 547.84 671.1031609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 41 558.13 683.7131609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 42 567.99 695.7831609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 43 581.71 712.5931609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 44 598.85 733.5931609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 45 619.00 758.2731609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 46 643.01 787.6831609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 47 670.01 820.7631609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 48 700.88 858.5731609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 49 731.31 895.8631609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 50 765.60 1052.7131609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 51 799.47 1099.2731609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 52 836.76 1150.5531609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 53 874.49 1202.4231609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 54 915.21 1258.4131609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 55 955.93 1314.4131609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 56 1000.09 1375.1231609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 57 1044.67 1436.4231609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 58 1092.25 1501.8531609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 59 1115.83 1534.2631609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 60 1163.41 1599.6931609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 61 1204.56 1656.2731609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 62 1231.57 1693.4131609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 63 1265.43 1739.9731609PA0150028 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1286.01 1768.2631609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 267.94 267.9431609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 15 291.76 291.7631609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 16 300.86 300.8631609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 17 309.97 309.9731609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 18 319.78 319.7831609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 19 329.59 329.5931609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 20 339.74 339.7431609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 21 350.25 394.0331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 22 350.25 394.0331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 23 350.25 394.0331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 24 350.25 394.0331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 25 351.65 395.6131609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 26 358.66 403.4931609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 27 367.06 412.9431609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 28 380.72 428.3131609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 29 391.93 440.9231609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 30 397.53 467.1031609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 31 405.94 476.9831609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 32 414.35 486.8631609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 33 419.60 493.0331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 34 425.20 499.6131609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 35 428.01 502.9131609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 36 430.81 506.2031609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 37 433.61 509.4931609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 38 436.41 512.7831609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 39 442.02 519.3731609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 40 447.62 548.3331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 41 456.03 558.6331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 42 464.08 568.5031609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 43 475.29 582.2331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 44 489.30 599.3931609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 45 505.76 619.5631609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 46 525.38 643.5831609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 47 547.44 670.6131609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 48 572.66 701.5131609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 49 597.53 731.9731609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 50 625.55 860.1331609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 51 653.22 898.1731609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 52 683.69 940.0731609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 53 714.51 982.4531609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 54 747.78 1028.2031609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 55 781.06 1073.9531609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 56 817.13 1123.5631609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 57 853.56 1173.6431609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 58 892.44 1227.1031609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 59 911.70 1253.5931609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 60 950.58 1307.0531609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 61 984.20 1353.2831609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 62 1006.27 1383.6231609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 63 1033.94 1421.6631609PA0150029 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1050.75 1444.7831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 372.97 372.9731609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 15 406.12 406.1231609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 16 418.80 418.80

31609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 17 431.47 431.4731609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 18 445.12 445.1231609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 19 458.78 458.7831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 20 472.91 472.9131609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 21 487.54 548.4831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 22 487.54 548.4831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 23 487.54 548.4831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 24 487.54 548.4831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 25 489.49 550.6831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 26 499.24 561.6531609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 27 510.94 574.8131609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 28 529.96 596.2031609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 29 545.56 613.7531609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 30 553.36 650.2031609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 31 565.06 663.9431609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 32 576.76 677.6931609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 33 584.07 686.2931609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 34 591.87 695.4531609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 35 595.77 700.0331609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 36 599.67 704.6231609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 37 603.57 709.2031609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 38 607.47 713.7831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 39 615.28 722.9531609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 40 623.08 763.2731609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 41 634.78 777.6031609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 42 645.99 791.3431609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 43 661.59 810.4531609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 44 681.09 834.3431609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 45 704.01 862.4131609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 46 731.31 895.8531609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 47 762.03 933.4831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 48 797.13 976.4831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 49 831.74 1018.8931609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 50 870.75 1197.2831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 51 909.26 1250.2431609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 52 951.68 1308.5631609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 53 994.58 1367.5531609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 54 1040.90 1431.2331609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 55 1087.21 1494.9231609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 56 1137.43 1563.9731609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 57 1188.13 1633.6931609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 58 1242.25 1708.1031609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 59 1269.07 1744.9731609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 60 1323.18 1819.3831609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 61 1369.99 1883.7331609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 62 1400.70 1925.9731609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 63 1439.22 1978.9231609PA0150030 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1462.62 2011.1031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 310.96 310.9631609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 15 338.61 338.6131609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 16 349.17 349.1731609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 17 359.74 359.7431609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 18 371.13 371.1331609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 19 382.51 382.5131609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 20 394.30 394.3031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 21 406.49 457.3031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 22 406.49 457.3031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 23 406.49 457.3031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 24 406.49 457.3031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 25 408.12 459.1331609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 26 416.25 468.2831609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 27 426.00 479.2531609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 28 441.85 497.0931609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 29 454.86 511.7231609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 30 461.37 542.1131609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 31 471.12 553.5731609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 32 480.88 565.0331609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 33 486.98 572.2031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 34 493.48 579.8431609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 35 496.73 583.6631609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 36 499.98 587.4831609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 37 503.23 591.3031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 38 506.49 595.1231609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 39 512.99 602.7631609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 40 519.49 636.3831609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 41 529.25 648.3331609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 42 538.60 659.7831609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 43 551.61 675.7231609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 44 567.87 695.6431609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 45 586.97 719.0431609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 46 609.74 746.9331609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 47 635.34 778.3031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 48 664.61 814.1531609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 49 693.47 849.5031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 50 725.99 998.2431609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 51 758.10 1042.3931609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 52 793.47 1091.0231609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 53 829.24 1140.2031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 54 867.86 1193.3031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 55 906.47 1246.4031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 56 948.34 1303.9731609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 57 990.62 1362.1031609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 58 1035.74 1424.1431609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 59 1058.09 1454.8831609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 60 1103.21 1516.9231609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 61 1142.24 1570.5831609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 62 1167.85 1605.7931609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 63 1199.96 1649.9431609PA0150031 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1219.47 1676.7731609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 361.73 361.7331609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 15 393.88 393.8831609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 16 406.18 406.1831609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 17 418.47 418.4731609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 18 431.71 431.7131609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 19 444.95 444.9531609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 20 458.66 458.6631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 21 472.85 531.9631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 22 472.85 531.9631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 23 472.85 531.9631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 24 472.85 531.9631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 25 474.74 534.0831609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 26 484.20 544.7231609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 27 495.55 557.4931609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 28 513.99 578.2431609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 29 529.12 595.2631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 30 536.68 630.6031609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 31 548.03 643.9431609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 32 559.38 657.2731609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 33 566.47 665.6131609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 34 574.04 674.5031609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 35 577.82 678.9431609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 36 581.61 683.3931609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 37 585.39 687.8331609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 38 589.17 692.2831609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 39 596.74 701.1731609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 40 604.30 740.2731609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 41 615.65 754.1731609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 42 626.53 767.4931609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 43 641.66 786.0331609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 44 660.57 809.2031609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 45 682.80 836.4231609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 46 709.28 868.8631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 47 739.06 905.3531609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 48 773.11 947.0631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 49 806.68 988.1931609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 50 844.51 1161.2031609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 51 881.87 1212.5631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 52 923.00 1269.1331609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 53 964.61 1326.34

31609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 54 1009.53 1388.1131609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 55 1054.46 1449.8831609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 56 1103.16 1516.8431609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 57 1152.34 1584.4631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 58 1204.82 1656.6331609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 59 1230.83 1692.3931609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 60 1283.31 1764.5631609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 61 1328.71 1826.9731609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 62 1358.50 1867.9331609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 63 1395.85 1919.3031609PA0150032 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1418.55 1950.5131609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 282.38 282.3831609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 15 307.49 307.4931609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 16 317.08 317.0831609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 17 326.68 326.6831609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 18 337.02 337.0231609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 19 347.35 347.3531609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 20 358.06 358.0631609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 21 369.13 415.2731609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 22 369.13 415.2731609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 23 369.13 415.2731609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 24 369.13 415.2731609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 25 370.61 416.9331609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 26 377.99 425.2431609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 27 386.85 435.2031609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 28 401.24 451.4031609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 29 413.06 464.6931609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 30 418.96 492.2831609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 31 427.82 502.6931609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 32 436.68 513.1031609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 33 442.22 519.6131609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 34 448.12 526.5531609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 35 451.08 530.0231609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 36 454.03 533.4931609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 37 456.98 536.9531609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 38 459.94 540.4231609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 39 465.84 547.3631609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 40 471.75 577.8931609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 41 480.61 588.7431609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 42 489.10 599.1431609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 43 500.91 613.6131609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 44 515.67 631.7031609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 45 533.02 652.9531609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 46 553.70 678.2831609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 47 576.95 706.7631609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 48 603.53 739.3231609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 49 629.74 771.4331609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 50 659.27 906.4931609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 51 688.43 946.5931609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 52 720.54 990.7431609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 53 753.03 1035.4131609PA0150033 Rating Area 8 Tobacco User/Non-Tobacco User 54 788.09 1083.6331609PA0150033 Rating Area 8 Tobacco 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394.59 463.6531609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 31 402.94 473.4531609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 32 411.28 483.2631609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 33 416.50 489.3831609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 34 422.06 495.9231609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 35 424.84 499.1931609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 36 427.62 502.4631609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 37 430.40 505.7231609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 38 433.18 508.9931609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 39 438.75 515.5331609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 40 444.31 544.2831609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 41 452.65 554.5031609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 42 460.65 564.3031609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 43 471.77 577.9231609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 44 485.68 594.9631609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 45 502.02 614.9831609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 46 521.49 638.8331609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 47 543.39 665.6631609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 48 568.42 696.3231609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 49 593.11 726.5631609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 50 620.92 853.7731609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 51 648.39 891.5331609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 52 678.63 933.1231609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 53 709.23 975.1931609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 54 742.25 1020.6031609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 55 775.28 1066.0131609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 56 811.09 1115.2531609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 57 847.25 1164.9731609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 58 885.84 1218.0331609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 59 904.96 1244.3231609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 60 943.55 1297.3831609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 61 976.92 1343.2731609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 62 998.83 1373.3931609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 63 1026.29 1411.1531609PA0150034 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1042.98 1434.1031609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 292.78 292.7831609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 15 318.81 318.8131609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 16 328.76 328.7631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 17 338.71 338.7131609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 18 349.42 349.4231609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 19 360.14 360.1431609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 20 371.24 371.2431609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 21 382.72 430.5631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 22 382.72 430.5631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 23 382.72 430.5631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 24 382.72 430.5631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 25 384.25 432.2831609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 26 391.91 440.8931609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 27 401.09 451.2331609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 28 416.02 468.0231609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 29 428.26 481.8031609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 30 434.39 510.4031609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 31 443.57 521.2031609PA0150035 Rating Area 8 Tobacco 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31609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 40 489.12 599.1731609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 41 498.30 610.4231609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 42 507.10 621.2031609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 43 519.35 636.2131609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 44 534.66 654.9631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 45 552.65 676.9931609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 46 574.08 703.2531609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 47 598.19 732.7831609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 48 625.75 766.5431609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 49 652.92 799.8331609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 50 683.54 939.8631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 51 713.77 981.4431609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 52 747.07 1027.2231609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 53 780.75 1073.5331609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 54 817.11 1123.5231609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 55 853.47 1173.5231609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 56 892.89 1227.7231609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 57 932.69 1282.4531609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 58 975.17 1340.8631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 59 996.22 1369.8031609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 60 1038.70 1428.2231609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 61 1075.44 1478.7331609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 62 1099.55 1511.8931609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 63 1129.79 1553.4631609PA0150035 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1148.16 1578.7231609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 200.35 200.3531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 15 218.16 218.1631609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 16 224.97 224.9731609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 17 231.78 231.7831609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 18 239.11 239.1131609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 19 246.45 246.4531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 20 254.04 254.0431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 21 261.90 294.6431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 22 261.90 294.6431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 23 261.90 294.6431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 24 261.90 294.6431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 25 262.95 295.8231609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 26 268.19 301.7131609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 27 274.47 308.7831609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 28 284.69 320.2731609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 29 293.07 329.7031609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 30 297.26 349.2831609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 31 303.54 356.6631609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 32 309.83 364.0531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 33 313.76 368.6631609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 34 317.95 373.5931609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 35 320.04 376.0531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 36 322.14 378.5131609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 37 324.23 380.9731609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 38 326.33 383.4331609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 39 330.52 388.3631609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 40 334.71 410.0231609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 41 340.99 417.7231609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 42 347.02 425.1031609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 43 355.40 435.3631609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 44 365.87 448.2031609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 45 378.18 463.2731609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 46 392.85 481.2431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 47 409.35 501.4531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 48 428.21 524.5531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 49 446.80 547.3331609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 50 467.75 643.1631609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 51 488.44 671.6131609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 52 511.23 702.9431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 53 534.28 734.6331609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 54 559.16 768.8431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 55 584.04 803.0531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 56 611.01 840.1431609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 57 638.25 877.5931609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 58 667.32 917.5731609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 59 681.73 937.3731609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 60 710.80 977.3531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 61 735.94 1011.9231609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 62 752.44 1034.6031609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 63 773.13 1063.0531609PA0150036 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 785.70 1080.3431609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 215.73 215.7331609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 15 234.91 234.9131609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 16 242.24 242.2431609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 17 249.57 249.5731609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 18 257.47 257.4731609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 19 265.36 265.3631609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 20 273.54 273.5431609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 21 282.00 317.2531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 22 282.00 317.2531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 23 282.00 317.2531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 24 282.00 317.2531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 25 283.13 318.5231609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 26 288.77 324.8631609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 27 295.54 332.4831609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 28 306.53 344.8531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 29 315.56 355.0031609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 30 320.07 376.0831609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 31 326.84 384.0331609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 32 333.61 391.9931609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 33 337.84 396.9631609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 34 342.35 402.2631609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 35 344.60 404.9131609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 36 346.86 407.5631609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 37 349.12 410.2131609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 38 351.37 412.8631609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 39 355.88 418.1631609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 40 360.40 441.4931609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 41 367.16 449.7831609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 42 373.65 457.7231609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 43 382.67 468.7831609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 44 393.95 482.5931609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 45 407.21 498.8331609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 46 423.00 518.1831609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 47 440.77 539.9431609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 48 461.07 564.8131609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 49 481.09 589.3431609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 50 503.65 692.5231609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 51 525.93 723.1531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 52 550.46 756.8931609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 53 575.28 791.0131609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 54 602.07 827.8531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 55 628.86 864.6831609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 56 657.91 904.6231609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 57 687.23 944.9531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 58 718.54 987.9931609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 59 734.05 1009.3131609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 60 765.35 1052.3531609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 61 792.42 1089.5831609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 62 810.19 1114.0131609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 63 832.46 1144.6431609PA0150037 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 846.00 1163.2531609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 327.63 327.6331609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 15 356.75 356.7531609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 16 367.88 367.8831609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 17 379.02 379.0231609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 18 391.01 391.0131609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 19 403.00 403.0031609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 20 415.42 415.4231609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 21 428.27 481.8031609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 22 428.27 481.8031609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 23 428.27 481.8031609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 24 428.27 481.8031609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 25 429.98 483.73

31609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 26 438.55 493.3731609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 27 448.83 504.9331609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 28 465.53 523.7231609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 29 479.23 539.1431609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 30 486.09 571.1531609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 31 496.36 583.2331609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 32 506.64 595.3131609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 33 513.07 602.8531609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 34 519.92 610.9131609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 35 523.35 614.9331609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 36 526.77 618.9631609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 37 530.20 622.9831609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 38 533.62 627.0131609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 39 540.48 635.0631609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 40 547.33 670.4831609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 41 557.61 683.0731609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 42 567.46 695.1431609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 43 581.16 711.9231609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 44 598.29 732.9131609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 45 618.42 757.5731609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 46 642.41 786.9531609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 47 669.39 820.0031609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 48 700.22 857.7731609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 49 730.63 895.0231609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 50 764.89 1051.7231609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 51 798.72 1098.2431609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 52 835.98 1149.4831609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 53 873.67 1201.3031609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 54 914.36 1257.2431609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 55 955.04 1313.1831609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 56 999.15 1373.8431609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 57 1043.69 1435.0831609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 58 1091.23 1500.4431609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 59 1114.79 1532.8331609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 60 1162.32 1598.2031609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 61 1203.44 1654.7331609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 62 1230.42 1691.8331609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 63 1264.25 1738.3531609PA0150047 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1284.81 1766.6131609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 231.01 231.0131609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 15 251.55 251.5531609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 16 259.40 259.4031609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 17 267.25 267.2531609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 18 275.71 275.7131609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 19 284.16 284.1631609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 20 292.92 292.9231609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 21 301.98 339.7331609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 22 301.98 339.7331609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 23 301.98 339.7331609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 24 301.98 339.7331609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 25 303.19 341.0931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 26 309.23 347.8831609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 27 316.48 356.0331609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 28 328.25 369.2831609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 29 337.92 380.1631609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 30 342.75 402.7331609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 31 349.99 411.2431609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 32 357.24 419.7631609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 33 361.77 425.0831609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 34 366.60 430.7631609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 35 369.02 433.6031609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 36 371.44 436.4431609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 37 373.85 439.2831609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 38 376.27 442.1131609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 39 381.10 447.7931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 40 385.93 472.7631609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 41 393.18 481.6431609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 42 400.12 490.1531609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 43 409.79 501.9931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 44 421.87 516.7931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 45 436.06 534.1731609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 46 452.97 554.8931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 47 471.99 578.1931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 48 493.74 604.8331609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 49 515.18 631.0931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 50 539.34 741.5931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 51 563.19 774.3931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 52 589.46 810.5131609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 53 616.04 847.0531609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 54 644.73 886.5031609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 55 673.42 925.9531609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 56 704.52 968.7131609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 57 735.93 1011.9031609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 58 769.45 1057.9931609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 59 786.05 1080.8231609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 60 819.57 1126.9131609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 61 848.56 1166.7831609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 62 867.59 1192.9331609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 63 891.44 1225.7431609PA0150048 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 905.94 1245.6731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 237.50 237.5031609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 15 258.61 258.6131609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 16 266.69 266.6931609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 17 274.76 274.7631609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 18 283.45 283.4531609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 19 292.14 292.1431609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 20 301.15 301.1531609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 21 310.46 349.2731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 22 310.46 349.2731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 23 310.46 349.2731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 24 310.46 349.2731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 25 311.70 350.6631609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 26 317.91 357.6531609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 27 325.36 366.0331609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 28 337.47 379.6531609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 29 347.40 390.8331609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 30 352.37 414.0431609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 31 359.82 422.7931609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 32 367.27 431.5531609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 33 371.93 437.0231609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 34 376.90 442.8631609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 35 379.38 445.7731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 36 381.87 448.6931609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 37 384.35 451.6131609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 38 386.83 454.5331609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 39 391.80 460.3731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 40 396.77 486.0431609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 41 404.22 495.1731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 42 411.36 503.9231609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 43 421.29 516.0931609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 44 433.71 531.3031609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 45 448.30 549.1731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 46 465.69 570.4731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 47 485.25 594.4331609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 48 507.60 621.8131609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 49 529.64 648.8131609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 50 554.48 762.4131609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 51 579.01 796.1431609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 52 606.02 833.2731609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 53 633.34 870.8431609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 54 662.83 911.3931609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 55 692.33 951.9531609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 56 724.30 995.9231609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 57 756.59 1040.3131609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 58 791.05 1087.7031609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 59 808.13 1111.1831609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 60 842.59 1158.5631609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 61 872.39 1199.5431609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 62 891.95 1226.43

31609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 63 916.48 1260.1631609PA0150049 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 931.38 1280.6531609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 294.65 294.6531609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 15 320.84 320.8431609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 16 330.85 330.8531609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 17 340.87 340.8731609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 18 351.65 351.6531609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 19 362.44 362.4431609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 20 373.61 373.6131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 21 385.16 433.3131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 22 385.16 433.3131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 23 385.16 433.3131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 24 385.16 433.3131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 25 386.70 435.0431609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 26 394.40 443.7031609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 27 403.65 454.1031609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 28 418.67 471.0031609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 29 430.99 484.8731609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 30 437.16 513.6631609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 31 446.40 524.5231609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 32 455.64 535.3831609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 33 461.42 542.1731609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 34 467.58 549.4131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 35 470.67 553.0331609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 36 473.75 556.6531609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 37 476.83 560.2731609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 38 479.91 563.8931609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 39 486.07 571.1331609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 40 492.23 602.9931609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 41 501.48 614.3131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 42 510.34 625.1631609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 43 522.66 640.2631609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 44 538.07 659.1331609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 45 556.17 681.3131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 46 577.74 707.7331609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 47 602.01 737.4631609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 48 629.74 771.4331609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 49 657.08 804.9331609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 50 687.90 945.8631609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 51 718.32 987.6931609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 52 751.83 1033.7731609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 53 785.73 1080.3731609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 54 822.32 1130.6931609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 55 858.91 1181.0031609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 56 898.58 1235.5531609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 57 938.63 1290.6231609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 58 981.39 1349.4131609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 59 1002.57 1378.5431609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 60 1045.32 1437.3231609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 61 1082.30 1488.1631609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 62 1106.56 1521.5331609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 63 1136.99 1563.3631609PA0150050 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1155.48 1588.7931609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 245.76 245.7631609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 15 267.60 267.6031609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 16 275.95 275.9531609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 17 284.31 284.3131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 18 293.30 293.3031609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 19 302.30 302.3031609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 20 311.61 311.6131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 21 321.25 361.4131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 22 321.25 361.4131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 23 321.25 361.4131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 24 321.25 361.4131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 25 322.54 362.8531609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 26 328.96 370.0831609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 27 336.67 378.7531609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 28 349.20 392.8531609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 29 359.48 404.4131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 30 364.62 428.4331609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 31 372.33 437.4931609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 32 380.04 446.5531609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 33 384.86 452.2131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 34 390.00 458.2531609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 35 392.57 461.2731609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 36 395.14 464.2931609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 37 397.71 467.3131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 38 400.28 470.3331609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 39 405.42 476.3731609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 40 410.56 502.9331609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 41 418.27 512.3831609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 42 425.66 521.4331609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 43 435.94 534.0231609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 44 448.79 549.7631609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 45 463.89 568.2631609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 46 481.88 590.3031609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 47 502.11 615.0931609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 48 525.24 643.4231609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 49 548.05 671.3631609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 50 573.75 788.9131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 51 599.13 823.8131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 52 627.08 862.2431609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 53 655.35 901.1131609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 54 685.87 943.0731609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 55 716.39 985.0331609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 56 749.48 1030.5331609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 57 782.89 1076.4731609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 58 818.55 1125.5031609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 59 836.21 1149.7931609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 60 871.87 1198.8231609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 61 902.71 1241.2331609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 62 922.95 1269.0631609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 63 948.33 1303.9531609PA0170001 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 963.75 1325.1631609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 0-14 328.45 328.4531609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 15 357.65 357.6531609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 16 368.81 368.8131609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 17 379.97 379.9731609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 18 392.00 392.0031609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 19 404.02 404.0231609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 20 416.47 416.4731609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 21 429.35 483.0231609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 22 429.35 483.0231609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 23 429.35 483.0231609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 24 429.35 483.0231609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 25 431.07 484.9531609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 26 439.65 494.6131609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 27 449.96 506.2031609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 28 466.70 525.0431609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 29 480.44 540.5031609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 30 487.31 572.5931609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 31 497.62 584.7031609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 32 507.92 596.8131609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 33 514.36 604.3731609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 34 521.23 612.4531609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 35 524.67 616.4831609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 36 528.10 620.5231609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 37 531.54 624.5531609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 38 534.97 628.5931609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 39 541.84 636.6631609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 40 548.71 672.1731609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 41 559.01 684.7931609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 42 568.89 696.8931609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 43 582.63 713.7231609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 44 599.80 734.7631609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 45 619.98 759.4831609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 46 644.03 788.9331609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 47 671.07 822.0731609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 48 701.99 859.93

31609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 49 732.47 897.2831609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 50 766.82 1054.3831609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 51 800.74 1101.0131609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 52 838.09 1152.3831609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 53 875.87 1204.3331609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 54 916.66 1260.4131609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 55 957.45 1316.4931609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 56 1001.67 1377.3031609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 57 1046.33 1438.7031609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 58 1093.98 1504.2331609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 59 1117.60 1536.7031609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 60 1165.26 1602.2331609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 61 1206.47 1658.9031609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 62 1233.52 1696.0931609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 63 1267.44 1742.7331609PA0150039 Rating Area 8 Tobacco User/Non-Tobacco User 64 and over 1288.05 1771.07















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Cover Page

HIOS Issuer ID: 31609

HIOS Product ID: 31609PA015

This PDF file contains an actuarial certification for the unique plan designs under Issuer ID

31609. Please refer to all of the pages contained herein.

Unique Plan Design Supporting

Documentation and Justification ACTUARIAL MEMORANDUM

HIOS Issuer ID: 31609

HIOS Product IDs: 31609PA015

Applicable HIOS Plan IDs (Standard Component): 31609PA0150025, 31609PA0150026,

31609PA0150027, 31609PA0150028, 31609PA0150047, 31609PA0150049, 31609PA0150048,

31609PA0150029

Purpose of document:

The purpose of this document is to provide CMS with a justification of the methods used in

calculating the actuarial value for unique plan designs offered in the individual or small group

market for the plan year beginning 1/1/2020. As prescribed by law, the AV calculation was based

on the AV calculator to the full extent possible. The AV is meant to represent the average percent

of costs paid by the insurer for a standard population and may vary from actual member

experience. The resulting AV was based on prescribed methodology and, therefore, may not

reasonably reflect the actuary’s estimate of the portion of allowed costs covered by the health

insurance plan. The AV was determined based on the plan’s benefits and coverage data, the

standard population, and utilization and continuance tables published by HHS for purposes of the

valuation of AV. This actuarial analysis is not appropriate for any other purposes.

Reasons the plan design is unique (benefits that are not compatible with the parameters of

the AV calculator and the materiality of those benefits):

The cost-sharing for laboratory outpatient and professional services varies by site of service. Lab

work done at the office or a free-standing facility has zero cost-sharing, while lab work done by a

hospital has 50% coinsurance after deductible (if applicable). Laboratory outpatient and

professional services account for roughly 3% of allowed costs in the AV calculation.

The cost-sharing for occupational and physical therapy varies by site of service. Occupational

and physical therapy accounts for roughly 2% of allowed costs in the AV calculation.

The cost-sharing for x-rays and diagnostic imaging varies by site of service. X-rays and

diagnostic imaging accounts for roughly 4% of allowed costs in the AV calculation.

The cost-sharing for imaging (CT/PET scans, MRIs) varies by site of service. Imaging accounts

for roughly 2% of allowed costs in the AV calculation.

31609PA0150028, 31609PA0150047, 31609PA0150048, and 31609PA0150029 have cost-

sharing for outpatient facility fee which varies by site of service. Outpatient facility fee accounts

for roughly 12% of allowed costs in the AV calculation.

Acceptable alternate method used per 156.135(b)(2) or 156.135(b)(3):

Method 156.135(b)(2) was used for laboratory (for plans with no deductible), x-rays, imaging,

and outpatient facility site of service cost-sharing.

Method 156.135(b)(3) was used for laboratory site of service cost-sharing (for plans with

deductibles).

Confirmation that only in-network cost-sharing, including multitier networks, was

considered:

I confirm that only in-network cost-sharing was considered.

Description of the standardized plan population data used:

For the freestanding and hospital utilization data for outpatient facility, we used our commercial

PPO and HMO data incurred between July 2017 and June 2018.

For the physical therapy and radiology site-of-service utilization, we used our commercial PPO

data incurred between July 2017 and June 2018.

For the freestanding and hospital utilization data for laboratory services, we used our

commercial PPO data incurred between July 2017 and June 2018.

If the method described in 156.135(b)(2) was used, a description of how the benefits were

modified to fit the parameters of the AV calculator:

Laboratory Site-of-service Differential for Plans with No Deductible

For the lab site of service cost-sharing, our recent data suggested that 20% of units are at a

hospital setting with an average unit cost of $52.82, while 80% of units are at a freestanding

setting with an average unit cost of $19.08. Taking a weighted average of a 50% issuer

coinsurance applied to $52.82 and a 100% issuer coinsurance applied to $19.08 produced an

average issuer paid amount of $20.29 out of an average cost of $24.63, giving an effective issuer

coinsurance of 82.4% which was entered into the AV calculator.

Occupational and Physical Therapy Site-of-service Differential

For the physical therapy site of service cost-sharing, our recent data indicated that 88 % of

utilization came from the preferred site. The cost-sharing entered into the AV calculator is a

weighted average of the copays at each site.

X-rays and Diagnostic Imaging Site-of-service Copay Differential

For the x-ray site of service cost-sharing, our recent data indicated that 45% of utilization came

from the preferred site. The cost-sharing entered into the AV calculator is a weighted average of

copays based on utilization at each site.

X-rays and Diagnostic Imaging Site-of-service Coinsurance Differential

For the x-ray site of service cost-sharing, our recent data indicated that 20% of claims came from

the preferred site. The cost-sharing entered into the AV calculator is a weighted average of

coinsurance based on claims at each site.

Imaging (CT/PET scans, MRIs) Site-of-service Copay Differential

For the imaging site of service cost-sharing, our recent data indicated that 45% of utilization

came from the preferred site. The cost-sharing entered into the AV calculator is a weighted

average of copays based on utilization at each site.

Imaging (CT/PET scans, MRIs) Site-of-service Coinsurance Differential

For the imaging site of service cost-sharing, our recent data indicated that 25% of claims came

from the preferred site. The cost-sharing entered into the AV calculator is a weighted average of

coinsurance based on claims at each site.

Outpatient Facility Fee Site-of-service Differential

For the outpatient facility site of service cost-sharing, our recent data indicated that 80% of

outpatient facility claims came from the hospital setting.

The cost-sharing entered into the AV calculator is a weighted average of the coinsurance at a

hospital and the coinsurance at an ambulatory surgery center.

Cost-sharing

HIOS ID Service Type Preferred Site Non-preferred Site AV Input

Phys. Ther. $20 $50 $23.60

31609PA0150025 X-rays $70 $100 $86.50

Imaging $175 $215 $197.00

Phys. Ther. $40 $70 $43.60

31609PA0150026 X-rays $70 $100 $86.50

Imaging $175 $215 $197.00

Phys. Ther. $80 $110 $83.60

31609PA0150027 X-rays $100 $130 $116.50

Imaging $250 $290 $272.00

Phys. Ther. $40 $80 $44.80

31609PA0150028 X-rays 80% 60% 64%

Imaging 80% 60% 65%

OP Facility 80% 50% 56%

Phys. Ther. $80 $110 $83.60

31609PA0150047 X-rays $70 $100 $86.50

Imaging $175 $215 $197.00


Phys. Ther. $80 $110 $83.60

31609PA0150049 X-rays $100 $130 $116.50

Imaging $250 $290 $272.00

Phys. Ther. $100 $130 $103.60

31609PA0150048 X-rays $100 $130 $116.50

Imaging $250 $290 $272.00


Phys. Ther. $60 $90 $63.60

31609PA0150029 X-rays 70% 50% 54%

Imaging 70% 50% 55%


If the method described in 156.135(b)(3) was used, a description of the data and method

used to develop the adjustments:

Laboratory Site-of-service Differential for Plans with Deductible

For the lab site of service cost-sharing, our recent data indicated that 20% of lab claims came

from the hospital setting.

Using the AV calculation resulting from method 156.135(b)(2), two separate AVs were

calculated; the first AV was calculated with zero lab cost-sharing to reflect lab work done by at

an office or free-standing facility, and the second AV was calculated with 50% coinsurance after

deductible to reflect lab work done by a hospital. The final AV for the plan was then calculated

by taking a weighted average of the two AVs using the utilizations by lab site. The following

exhibit details this calculation.

AV

HIOS ID Free-standing Hospital Average

31609PA0150028 79.87% 78.53% 79.60%

31609PA0150047 80.73% 79.05% 80.39% 31609PA0150049 72.29% 70.47% 71.93% 31609PA0150048 71.94% 70.02% 71.56% 31609PA0150029 72.25% 70.57% 71.91%

Utilization 80% 20%

Certification Language:

The development of the actuarial value is based on one of the acceptable alternative methods outlined

in 156.135(b)(2) or 156.135(b)(3) for those benefits that deviate substantially from the parameters of

the AV Calculator and have a material impact on the AV.

The analysis was

(i) conducted by a member of the American Academy of Actuaries; and

(ii) performed in accordance with generally accepted actuarial principles and methodologies.

I am an employee of the issuer, I meet the Qualification Standards for Actuaries Issuing

Statements of Actuarial Opinion in the United States promulgated by the American Academy of

Actuaries, and I have the education and experience necessary to perform this work. All AVs

herein were determined in accordance with the ASOPs established by the Actuarial Standards

Board and comply with applicable laws and regulations; furthermore, all metal levels herein

were appropriately assigned based on applicable law.

Actuary signature:

Actuary Printed Name:

Date: 5/21/2019

AV screenshots redacted.

No change was assumed.

The change in demographics was calculated considering changes to age, geography, and tobacco use.

The change in the average age was measured by comparing the average age factor calculated in this filing, based on February 2019 enrollments, to the average age factor calculated for the prior annual filing.

2019 2020Filing Filing Change

Age Factor 1.494 1.512 1.013

Change from geography: No change 1.000Change from tobacco use: No change 1.000

Total change 1.013

No changes were assumed for this filing.

The network factors used in Table 10 are based on the network differentials from the prior filing.

The network factor used for PPO was 1.000.The network factor used for EPO was 0.950.

The factors used in Table 10 recalibrate the values so that the differntials between the factors remains constant, and the composite factor equals 1.000.

Table 10 factors: PPO 1.000EPO 0.950

2018 KHPE Individual Rate Filing

REDACTION JUSTIFICATION

DOCUMENT

URRT Part III – Federal Actuarial Memorandum

Redacted Name of opining actuary (page 8)

Redacted Company Contact Information (page 1) – name, telephone number, email address

PA Actuarial Memorandum

Redacted Name of opining actuary (page 7)

Redacted Company Contact Information (page 1) – name, telephone number, email address

Cover Letter

Redacted names and contact information (page 2)

AV Screenshots

Entire File Redacted

Unique AV Justification file

Redacted name of opining actuary (pages 7)

Redacted AV Screenshots (pages 8-20)

INAC-131927133 1 Response Letter QCC Small Group 1Q2020 June 25, 2019

1. The updated URR instructions requires the quantitative impact of rate increase drivers. Please

estimate the impact to the rate increase of each of the drivers described on page 1 of the Part III

memorandum.

The information is shown in Tab #1 of the attached worksheet.

2. The updated URR instructions require an explanation of how morbidity was removed from

impacting the variations in rate increases. Please provide this explanation and provide a

quantitative demonstration of the variation in rate increase by plan.

We have held our rate increases constant by plan design across the single risk pool except for

differences in changes in cost sharing between plan design. In this way the morbidity impact by plan

was removed from the rate increases because if the plans had the same benefit changes, they would

have received the same rate increase regardless of what their plan specific experience was. Please

note that the benefit changes made resulted in reductions to the Pricing AVs.

Please also see our response to question 33 for more details of these calculations.

3. Was transitional business included in the experience period?

QCC has no transitional business in the Small Group market.

4. Please correct several sections of the part III memorandum that refer to individual instead of

small group.

We have made these corrections.

5. Please confirm that the experience period premiums on the URRT do not reflect any MLR

rebates.

Confirmed, there are no MLR rebates reflected in the experience period premiums.

6. For both the allowed and incurred claims in the experience period, please provide the three

components referenced in the Part III memo:

a. The amount of claims that were processed through the claims system;

b. The amount of claims processed outside of the company’s claims system; and

c. The best estimate of claims incurred but not paid as of the paid through date.

This information is shown in Tab #6 of the attached worksheet. It is also found in Table 2 of the AM

Exhibit.

7. As required by the URR instructions, the Part III memorandum must state any scheduled small

group quarterly trend adjustments to the index rate.

We have added this information to the Part III memorandum.

8. Are trends adjusted due to fluctuation in large claim amounts? If so, please explain how.

Since we consider this block to be fully credible on its own, no adjustments were made for large

claims.


9. If adjustments are made for large claim pooling, was the federal risk adjustment program

considered?

No, because no adjustments were made for Large claims there was no need to adjust risk adjustment

10. The URR instructions specify the projected index rate should reflect the 1Q2019 index rate, not

the member weighted index rate as in the past. Please correct.

We followed the URR instructions as well as the PA instructions and believe our methodology is

appropriate.

11. Please provide quantitative support for the 1.023 “Other” adjustment shown in the URRT,

worksheet 1, cell F35. Please explain why it differs from the combined effect of the 1.006

network factor and the 1.000 “Change in Other” factor in the PAAM Exhibits.

This is shown in Tab #11 of the attached spreadsheet. It incorporates the quarterly adjustment from

Table 5a in the PAAM Exhibits to calculate the MAIR consistent with the PAAM Exhibits.

12. Please provide substantial quantitative support for the development of the projected risk

adjustment, and identify how the relative risk compared to the market was determined.

Information is shown in Tab #12 of the attached worksheet.

13. Please explain the discrepancy in the Adjusted Projected Allowed EHB Claims between Table 5

Cell C42 and URRT Worksheet 1 Cell F36.

The URRT restricts the number of decimal places that can be used in calculations which resulted in a

rounding difference.

14. Regarding the Risk Adjustment Data Validation process (RADV):

a. Please describe any considerations and provide quantitative support for any adjustments

made due to the Risk Adjustment Data Validation process (RADV), or confirm that no such

adjustments were made.

Confirmed that no adjustment was made for RADV in this filing.

b. As you know, CMS is performing a risk adjustment validation starting with 2017 risk

adjustment data. We are considering allowing an estimate of the impact of risk adjustment

modifications in rate filings as an adjustment to the projected risk adjustment. Before

implementation, we are soliciting feedback from our issuers on the pros and cons of the

inclusion of this adjustment. If allowed, all issuers would be required to submit an estimate.

The estimate may be $0. Please provide any feedback that you would like us to consider.

Independence is open to submitting an estimate of the impact of RADV on projected risk

adjustments, but we have several concerns:

• Commercial RADV is still a fairly new and evolving process. Carriers do not have sufficient

information to accurately estimate the RADV impact.


• Without releasing carriers’ proprietary information, it will be difficult to determine if RADV

impact is due to a systemic risk score reporting issue or due to one-time bad audit. In the case

of latter, carriers should not expect this experience to be reflective of the future.

Our preference remains to not include an adjustment.

15. The Pricing AV’s shown in Table 10 of the PAAM exhibits, which do not include the CSR load

or induced demand, are larger than the Metal AV in the URRT for all plans. What is driving

these differences?

Please note that the metal AV is to determine compliance with Actuarial Value and is not a Pricing

AV. The metal AV is based on the AV calculator which is calibrated to national average costs. The

Philadelphia market is significantly more expensive than the national average from a cost of services

standpoint. This means that the same deductible or copay is worth significantly less as a percentage of

total allowed cost in the Philadelphia market compared to the national average. This leads to higher

Pricing AVs for the same metal level. Please also refer to our response for question 19.

16. Please provide quantitative support for the Pricing AV’s as shown in Table 10 of the PAAM

exhibits, explain how they were developed, and explain how you ensure that the factors do not

reflect morbidity differences between the enrolled populations.

The information is shown in Tab #16 of the attached worksheet. The morbidity impact by plan has

been removed from the rate increases. Without the benefit changes, the plans would have received the

same rate increase regardless of what their plan specific experience was.

17. In support of the figures shown in Table 10, Column L, please complete the worksheet shown

on page 15 of the Department’s guidance as well as providing the following information related

to the worksheet:

a. Please confirm that the ratio in Column (9) represents the pure induced utilization for each

plan.

b. Please show quantitatively, including an Excel spreadsheet with formulas, the derivation of

the AV and cost sharing factors for each plan. Please note that it is assumed that the AV

and cost sharing factor includes the average tobacco factor.

c. Please provide any additional justification for induced utilization assumptions in the

Company’s pricing.

d. Please confirm that each plan’s induced utilization factor was normalized by an aggregate

factor, and that the resulting sum product (against 2/1/2019 membership or the projected

membership distribution) produces

e. Please quantitatively demonstrate the calculation of the induced calibration factor.

f. Please quantitatively show and provide a detailed description of how the induced demand

factor shown in Table 7 relates to the induced utilization factors calculated in this exhibit.

Information is shown in Tab #17.

We confirm that the value represents the factor for each plan. They are equal to the values shown

in Table 10 for each plan.

Table 10 demonstrates that when weighted by 2/1/2019 membership that the induced utilization

factors composite to 1.000.


It is unclear what is being requested about an induced calibration factor. However, as noted

above, the induced utilizations composite to 1.000.

The induced demand factor shown in Table 7 is the composite of the induced demand factors in

Table 10 of 1.000. We do not anticipate a change to our single risk pool costs from induced

demand in 2020.

18. Please explain why some gold and silver plans have lower induced demand factors than some

bronze plans.

Consistent with prior years, our 2020 induced demand factors do not differ from our approved 2019

induced demand factors in order to preserve the rate relationship we currently have in the market. We

maintained the same relationship used in the 2019 annual filing, and re-normalized them so that the

composite factor would be 1.000.

19. Given the 1.01 factor shown for “Benefits in addition to EHB” in cell M15 of Table 10, please

explain what non-EHB benefits were included and how the adjustments in the PAAM Table 10

were developed. I note that no non-EHB claims are shown in Cell H36 of Table 2.

This information is shown in Tab #19.

20. Regarding Table 6:

a. We have repurposed row 54 to capture RA User Fees. Please provide the RA User Fee

percentage and pmpm amount in cells C54 and D54, and identify where the risk adjustment

user fees are currently included in the URRT and in the PAAM. Note the URR instructions

specify that these fees are to be included in Taxes & Fees and not with the risk adjustment

transfers on the URRT.

At the direction of the state’s reviewer, we revised these cells to produce an RA User Fee of

$0.18 and removed that amount from the Risk Adjustment, resulting in no change to the proposed

rates.

b. Using financial data based on nationwide market share, please provide the quantitative

development of the HIT percent and pmpm.

Insufficient time was provided to produce an answer for this question, so we were unable to

respond.

c. Provide the actual paid HIT fees on a pmpm and percent of premium basis for calendar

years 2018 and 2016.

Insufficient time was provided to produce an answer for this question, so we were unable to

respond.

21. Please provide the quantitative development of the 2.7% for health insurer fee.

The health insurer fee was expected to be in the range of 2-3%. We used our estimate of 2.7% in

setting the rates.


22. Please show the quantitative development of the Age Calibration Factor of 1.512 which appears

in Table 10, Cell T4.


23. Please show the quantitative development of the Tobacco Calibration Factor of 1.013 which

appears in Table 10, Cell T6.


24. Please provide the estimated 2020 federal MLR calculation showing all adjustments.


25. The Actuarial certification in the Part III Actuarial Memorandum appears to be based on last

year’s URRT and instructions. For example, it refers to “the percent of total premium that

represents essential health benefits included in Worksheet 2, Sections III and IV,” which is not

part of the current URRT. Please revise the certification consistent with this year’s URR

instructions.

We have updated the actuarial certification.

26. Please provide the requested data in Table 4, Columns J and K of the PAAM exhibits, or

explain why this data is not available.

We did not provide this in our 2019 filing.

27. Please support the weights shown in Table 3, Column J, and provide the actual weights by

service category generated by the 2018 experience.

These weights are consistent with the weights used by benefit type in the URRT and they were

obtained from our internal data warehouse.” Tab #27 converts these to $ by multiplying the PMPMs

in the URRT by MMOS.

28. Please show the quantitative development of the Federal Income Tax figure shown in Table 6.


29. In Table 10, please provide the DOH Approval Date for each network.

We have added this information to Table 14.

30. For the expanded Bronze plans, please demonstrate that the copay is less than or equal to the

50% coinsurance for that category.

There are two Bronze plans. One has 50% coinsurance after deductible and the other has 0%

coinsurance after the deductible.

31. Please provide an exhibit that quantitatively shows a comparison of the actual to projected

claim cost pmpms for calendar years 2015-2018, as applicable.


Insufficient time was provided to produce an answer for this question, so we were unable to respond.

32. Please provide an exhibit showing the actual experience for calendar years 2014 – 2018 and the

projections for 2019 and 202 for the following categories: Member months, total administrative

expenses, total incurred claims, total premium, total actual paid taxes and fees, profit, annual

underwriting gain/loss and underwriting gain/loss pmpy. Also show how the financial gains and

losses reconcile with the Annual Financial Statements for those periods.

Insufficient time was provided to produce an answer for this question, so we were unable to respond.

33. Please provide an exhibit that shows, by HIOS Plan ID, a summary of benefit and cost sharing

changes for 2020 relative to the 2019 design for all plans to be offered in 2020. Include Pricing

AV columns for 2019 and 2020. Please show the approved 2019 Pricing AVs for all plans in the

2019 column and the proposed 2020 Pricing AVs in the 2020 column. Also, provide a

supporting worksheet that shows the quantitative development of the proposed factors in Table

10, in support of the overall change in benefits factor shown in Table 5.

This information is shown in Tab #33.

34. Please confirm that you have tested to ensure that the PID rate exhibits and the Federal rates

template included in this filing and in the binder are all the same.

We confirmed that this is correct.

QCC Small Group 2020 2019 ChangeChange in Morbidity 1.00 1.00 0.00%Taxes and Fees 5.84% 2.52% 3.32%Administrative Costs 14.65% 15.20% -0.55%Average Age Factor 1.512 1.494 1.25%Projected Allowed Claims 584.33$ $602.35 -2.99%Actual vs. Expected Experience 10.84%Rate Change 11.9%

#1 Rate Increase Drivers

QCC Small Group Allowed Claims Incurred Claimsa Claims processed through the claims system 437,743,313$ 363,459,821$ b Claims processed outside of the company's claims system 7,221,961$ 7,221,961$ c Incurred but not paid claims 5,756,494$

#6 Claims & IBNR

URRT Part IChange in Network Change in Other 1Q2020 Trend Factor Other Adjustment

1.000 1.000 0.978 1.023

AM Exhibits

#11 Other Adjustment

This is the risk adjustment calculation.

Wheres= State average premium * 0.86; PLRSi = plan i’s plan liability risk score; AVi = plan i’s metal level AV; ARFi = plan i’s allowable rating factor; IDFi = plan i’s induced demand factor; GCFi = plan i’s geographic cost factor;

PA Small Group

Metal BMMO PLRS ARF GCF IDF AV Product w Risk

Product w/o Risk PMPM

Platinum 451,752 1.715 1.494 1.021 1.150 0.900 2.013 1.579 56.47 Gold 856,080 1.317 1.485 1.021 1.080 0.800 1.452 1.310 (14.94) Silver 695,520 1.018 1.516 1.021 1.030 0.700 1.070 1.116 (60.01) Bronze 172,572 1.047 1.586 1.021 1.000 0.600 1.069 0.971 (13.40) Total 2,175,924 1.283 1.505 1.021 1.072 0.773 1.416 1.277 (14.40)

Estimated StateWide Average 1.353 481.67$ 1.49 1.00 1.079 0.788 1.461 1.271

#12 Risk Adjustment

2019 Annual Filing Proposed 2020 FilingPricing AV Pricing AV

31609PA0150025 Personal Choice PPO Platinum Preferred $10/$20/$150 0.938 0.935 -0.3% Increase OOPM by $500, IF Fac $200, SNF $100, ER $150, Radiology31609PA0150026 Personal Choice PPO Platinum Preferred $20/$40/$150 0.930 0.924 -0.6% Increase OOPM by $500, IF Fac $250, SNF $125, ER $17531609PA0150027 Personal Choice PPO Gold Preferred $35/$70/$600 0.878 0.853 -2.8% Increase OOPM to $8,150, ER to $500 and copays by $531609PA0150028 Personal Choice PPO Gold Classic $1,500/$15/$30/80% 0.791 0.774 -2.1% Increase OOPM to $6,500 and copays31609PA0150029 Personal Choice PPO Silver Classic $3,250/$30/$60/70% 0.743 0.732 -1.5% Increase Ded to $3,750, OOPM to $8,150 31609PA0150030 Personal Choice PPO Platinum HSA-50 $1,600/100% 0.926 0.906 -2.2% Increase OOPM to $6,900 and Ded to $1,800.31609PA0150031 Personal Choice PPO Gold HSA-25 $2,400/90% 0.831 0.819 -1.4% Increase OOPM to $6,900 and copays31609PA0150032 Personal Choice PPO Gold HSA-0 $1,900/100% 0.830 0.822 -1.0% Increase OOPM to $6,900 and Ded to $2,100.31609PA0150033 Personal Choice PPO Gold HSA-25 $2,600/80% 0.890 0.890 0.0% Increase OOPM to $6,90031609PA0150034 Personal Choice PPO Silver HSA-0 $2,100/70% 0.764 0.761 -0.4% Increase Gen to $15 and OOPM to $6,90031609PA0150035 Personal Choice PPO Silver HSA-0 $2,700/90% 0.765 0.755 -1.3% Increase Gen to $15 and OOPM to $6,900, Ded to $3,000.31609PA0150036 Personal Choice PPO Bronze HSA-0 $5,200/50% 0.624 0.622 -0.3% Increase Gen to $15 and OOPM to $6,90031609PA0150037 Personal Choice PPO Bronze HSA-0 $6,750/100% 0.624 0.626 0.3% Increase Ded and OOPM to $6,90031609PA0150039 Personal Choice PPO Gold HRA-25 $3,200/100% 0.820 0.811 -1.1% Increase Ded to $3,400 and OOPM to $6,90031609PA0150047 Personal Choice PPO Gold Classic $2,500 $40/$80/100% 0.812 0.812 0.0% Increase OOPM $5,000 31609PA0150048 Personal Choice PPO Silver Classic $4,750/$50/$100/90% 0.758 0.742 -2.1% Increase Ded $5,000, OOPM to $8,150, ER 450, RX Gen to $1531609PA0150049 Personal Choice PPO Silver Secure $4,500/$35/$70/$600 0.753 0.728 -3.3% Increase Ded $4,750, OOPM to $8,150, PCP and Spec copays and Radiology, RX Gen to $1531609PA0150050 Personal Choice PPO Silver HSA-0 $3,200/100% 0.766 0.760 -0.8% Increase Gen to $15 and OOPM to $6,900, Ded to $3,500.31609PA0170001 Personal Choice EPO Silver HSA-0 $3,000/80% 0.725 0.722 -0.4% Increase Gen to $15 and OOPM to $6,900

HIOS ID Plan Name Difference Summary of Key Benefits Changes

#16 Pricing AVs

Table B: Induced Utilization ExhibitPlan ID Metal Level Projected

MembershipProjected

Allowed ClaimsProjected Paid

ClaimsPaid-To Allowed Factor

Average Tobacco Factor

AV & Cost Sharing Factor

(8)/ (6*7)

(1) (2) (3) (4) (5) (6) (7) (8) (9)31609PA0150025 Platinum 89,976 67,097,375 62,758,645 0.93534 1.013 1.12224 1.1844331609PA0150026 Platinum 144,048 103,539,858 95,637,285 0.92368 1.013 1.06822 1.1416531609PA0150027 Gold 165,540 102,936,343 87,784,228 0.85280 1.013 0.85321 0.9876431609PA0150028 Gold 20,892 14,044,923 10,877,649 0.77449 1.013 0.83771 1.0677531609PA0150029 Silver 29,412 17,101,060 12,512,255 0.73167 1.013 0.68447 0.9234831609PA0150030 Platinum 12,360 8,076,485 7,319,221 0.90624 1.013 0.95277 1.0378531609PA0150031 Gold 14,880 8,975,338 7,346,628 0.81854 1.013 0.79438 0.9580331609PA0150032 Gold 24,276 16,967,528 13,942,217 0.82170 1.013 0.92405 1.1101331609PA0150033 Gold 1,272 640,779 570,293 0.89000 1.013 0.72136 0.8001231609PA0150034 Silver 12,768 7,084,216 5,391,547 0.76106 1.013 0.67941 0.8812531609PA0150035 Silver 22,176 13,646,238 10,308,489 0.75541 1.013 0.74792 0.9773731609PA0150036 Bronze 91,020 46,573,353 28,953,716 0.62168 1.013 0.51181 0.8127031609PA0150037 Bronze 49,536 27,122,705 16,966,879 0.62556 1.013 0.55109 0.8696531609PA0150039 Gold 9,516 6,116,008 4,962,493 0.81139 1.013 0.83905 1.0208131609PA0150047 Gold 43,524 27,882,036 22,640,213 0.81200 1.013 0.83694 1.0174831609PA0150048 Silver 16,872 8,335,889 6,188,314 0.74237 1.013 0.59013 0.7847231609PA0150049 Silver 32,688 16,933,564 12,325,996 0.72790 1.013 0.60670 0.8227931609PA0150050 Silver 69,996 43,072,783 32,745,474 0.76024 1.013 0.75269 0.9773731609PA0170001 Silver 8,352 4,512,875 3,258,876 0.72213 1.013 0.66084 0.90338Total 859,104 540,659,354 442,490,419 0.81843 1.013

#17 Induced Utilization

Non-EHB Benefits %Elective abortion 0.10%Acupuncture 0.10%Adult Vision 0.75%Total 0.95%

Benefits in addtion to EHB 1.010

#19 Non-EHB

Age Member Count Age Factor QCC Small Group Age Calibration0 510 0.765 1.512 1 667 0.7652 718 0.7653 707 0.7654 682 0.7655 773 0.7656 702 0.7657 791 0.7658 727 0.7659 867 0.765

10 820 0.76511 865 0.76512 910 0.76513 965 0.76514 973 0.76515 1043 0.83316 1010 0.85917 1068 0.88518 1096 0.91319 1129 0.94120 1186 0.9721 1093 122 1192 123 1146 124 1126 125 1074 1.00426 974 1.02427 1016 1.04828 1072 1.08729 1035 1.11930 1120 1.13531 1071 1.15932 1094 1.18333 1110 1.19834 1089 1.21435 1071 1.22236 1041 1.2337 1028 1.23838 1068 1.24639 1044 1.26240 1032 1.27841 995 1.30242 953 1.32543 924 1.35744 1022 1.39745 1009 1.44446 1012 1.547 1082 1.56348 1230 1.63549 1208 1.70650 1323 1.78651 1319 1.86552 1355 1.95253 1359 2.0454 1369 2.13555 1472 2.2356 1416 2.33357 1412 2.43758 1589 2.54859 1464 2.60360 1397 2.71461 1382 2.8162 1449 2.87363 1351 2.95264 1195 365 501 366 225 367 176 368 104 369 94 370 69 371 55 372 51 373 43 374 28 375 35 376 22 377 19 378 13 379 16 380 11 381 15 382 8 383 3 384 7 385 5 386 5 387 8 388 5 389 1 390 3 391 2 392 2 393 0 394 2 395 0 399 0 3

100 0 3102 0 3

Total 71520

#22 Age Calibration

Age Projected Age Distribution Projected % Tobacco Use Approved Tobacco Factors0-20 25.46% 6.00% - 21-29 13.60% 6.00% 0.125 30-39 15.01% 6.00% 0.175 40-49 14.64% 7.00% 0.225 50-59 19.68% 7.00% 0.375 60-63 7.80% 7.00% 0.375 64+ 3.81% 7.00% 0.375 Total 100.00% 0.013

#23 Tobacco Calibration

Federal MLR =

QCC Small GroupProjected Claims PMPM (URRT) 515.06$ Premium PMPM (URRT) 664.49$ Quality Improvement Expense 0.80%Exchange User Fee & HIF 2.70%Federal Income Tax 1.14%Premium Tax 2.00%Federal MLR 83.2%

(Projected Claims, after Risk Adjustment + Quality Improvement Expense - Risk Adj Prog User Fee) (Premium, before Risk Adjustment - HCR Taxes & Fees - Federal Income Tax - Premium Tax)

#24 MLR Calculation

Member Months 838,663

Benefit Category Experience Period Index Rate PMPM Amount Weight Weight*

Inpatient Hospital $87.50 $73,383,012.50 16.88% 16.88%Outpatient Hospital $117.30 $98,375,169.90 22.63% 22.63%Professional $173.85 $145,801,562.55 33.54% 33.54%Other Medical $0.00 $0.00 0.00% 0.00%Capitation $8.61 $7,220,888.43 1.66% 1.66%Prescription Drug $131.14 $109,982,265.82 25.30% 25.30%Total $518.40 $434,762,899.20 100.00% 100.00%

Other Medical CapitationPrescription DrugsTotal

URRT Part I AM Exhibits

Service Category

Inpatient HospitalOutpatient Professional

#27 Servicy Category

Health Insurance Providers Fee (Prorated for Small Groups only) 2.70%Profit/Contingency (after tax) 2.00%Tax Rate 21.00%Federal Income Tax 1.14%

#28 Federal Income Tax

2019 Annual Filing Proposed 2020 Filing 2019 Annual Filing Proposed 2020 FilingPricing AV Pricing AV AV & Cost Sharing factors AV & Cost Sharing factors

31609PA0150025 Personal Choice PPO Platinum Preferred $10/$20/$150 0.938 0.935 -0.3% 1.1008 1.0831 -1.6%31609PA0150026 Personal Choice PPO Platinum Preferred $20/$40/$150 0.930 0.924 -0.6% 1.0520 1.0309 -2.0%31609PA0150027 Personal Choice PPO Gold Preferred $35/$70/$600 0.878 0.853 -2.8% 0.8592 0.8234 -4.2%31609PA0150028 Personal Choice PPO Gold Classic $1,500/$15/$30/80% 0.791 0.774 -2.1% 0.8368 0.8085 -3.4%31609PA0150029 Personal Choice PPO Silver Classic $3,250/$30/$60/70% 0.743 0.732 -1.5% 0.6798 0.6606 -2.8%31609PA0150030 Personal Choice PPO Platinum HSA-50 $1,600/100% 0.926 0.906 -2.2% 0.9522 0.9195 -3.4%31609PA0150031 Personal Choice PPO Gold HSA-25 $2,400/90% 0.831 0.819 -1.4% 0.7888 0.7666 -2.8%31609PA0150032 Personal Choice PPO Gold HSA-0 $1,900/100% 0.830 0.822 -1.0% 0.9129 0.8918 -2.3%31609PA0150033 Personal Choice PPO Gold HSA-25 $2,600/80% 0.890 0.890 0.0% 0.7056 0.6962 -1.3%31609PA0150034 Personal Choice PPO Silver HSA-0 $2,100/70% 0.764 0.761 -0.4% 0.6671 0.6557 -1.7%31609PA0150035 Personal Choice PPO Silver HSA-0 $2,700/90% 0.765 0.755 -1.3% 0.7408 0.7218 -2.6%31609PA0150036 Personal Choice PPO Bronze HSA-0 $5,200/50% 0.624 0.622 -0.3% 0.5025 0.4939 -1.7%31609PA0150037 Personal Choice PPO Bronze HSA-0 $6,750/100% 0.624 0.626 0.3% 0.5377 0.5319 -1.1%31609PA0150039 Personal Choice PPO Gold HRA-25 $3,200/100% 0.820 0.811 -1.1% 0.8294 0.8098 -2.4%31609PA0150047 Personal Choice PPO Gold Classic $2,500 $40/$80/100% 0.812 0.812 0.0% 0.8186 0.8077 -1.3%31609PA0150048 Personal Choice PPO Silver Classic $4,750/$50/$100/90% 0.758 0.742 -2.1% 0.5894 0.5695 -3.4%31609PA0150049 Personal Choice PPO Silver Secure $4,500/$35/$70/$600 0.753 0.728 -3.3% 0.6139 0.5855 -4.6%31609PA0150050 Personal Choice PPO Silver HSA-0 $3,200/100% 0.766 0.760 -0.8% 0.7418 0.7264 -2.1%31609PA0170001 Personal Choice EPO Silver HSA-0 $3,000/80% 0.725 0.722 -0.4% 0.6489 0.6378 -1.7%

HIOS ID Plan Name DifferencePlan Factor Change %

#33 Plan Relativity

INAC-131927133 1 Response Letter QCC Small Group 1Q2020 July 12, 2019

1. Please clarify how the Actual vs. Expected Experience was calculated in Table #1 submitted with

your response, and indicate how this change percentage relates to the Projected Allowed Claims

and other components of the rate change shown.

In the previous response we were using the Actual to expected to include all items of the rate increase not

included in the prior portions of the exhibits. We have re-labeled that section as the “residual difference”

and we have also updated the rate increase to match our re-filing due to risk adjustment results released

on June 28, 2019. This residual difference is now quite small (Only 1.30% in this filing).

2. Your response to item 6 of our previous objections shows no incurred but not paid claims for

allowed claims. Please explain or correct.

We did not include completion in the allowed claims, only in the incurred claims. We have adjusted all

exhibits to include the value of completion in the allowed claims.

Please note that in the rate build up, the utilization trend was adjusting for this, so we have lowered the

utilization trend so that the rates match what was previously filed.

We have updated our response for item 2 of this objection to clarity the components.

3. The total allowed and incurred claims shown in your response to item 6 of our previous

objections are $444,965,274 and $376,438,276 respectively. These amounts are greater than the

$434,762,544.21 and $360,479,052.22 shown in the URRT. Please explain or correct.

The claims in the URRT include Pharmacy rebate amounts. The response to item 5 of our previous

objection did not include Pharmacy rebate amount. The difference between the two is the value of the

pharmacy rebate, which can be found on Table 2 of the AM exhibits. We have updated our response for

item 2 of this objection to clarity the components.

4. Please clarify your response to item 10 of our previous objections. Your response to item 11 of

our previous objections makes clear that the projected index rate in the URRT is adjusted by the

weighted average of the quarterly trend factors and therefore is not the 1Q2019 index rate. Please

explain how this is consistent with the URR instructions, which state, “For annual filings, this

should be the Index Rate that applies for the first quarter” or remove the trend adjustment from

the “Other” adjustment.”

The projected index rate in the URRT is on a first quarter basis. Please compare the PAAM exhibits table

5 versus the URRT Worksheet 1. You will notice that the index rate in C37 of table 5 from the state

exhibits match the Index rate in the URRT. Therefore, we have set the URRT to a first quarter basis

otherwise those numbers would not match. Please also note that the rates in the URRT on Worksheet 2

match the 1Q rates in the PAAM on Table 11 column AC.

5. Regarding your response to item 17 of our previous objections, please revise or provide

substantial support for the induced utilization factors. The differences in the factors between metal

levels is substantially greater than the induced utilization factors used in the risk adjustment model.

Please see the attached exhibits.


6. Regarding your response to item 18 of our previous objections, the fact that it is the same as was

used last year is not adequate justification for some gold and silver plans having lower induced

demand factors than some bronze plans. Please provide further justification.

Thank you for clarifying this question. It appears that the concern is more specifically why does Personal

Choice PPO Bronze HSA-0 $6,750/100% have a higher induced demand factor than some of the Silver

and Gold plans. We have found that plans with 100% coinsurance tend to have higher induced demand

than plans that have some coinsurance attached. For example, the Personal Choice PPO Bronze HSA-0

$5,200/50% has a lower induced demand factor even though the out of pocket max for the two plans are

the same.

The existence of the 100% coinsurance also makes the induced demand of that plan higher than the

Personal Choice PPO Silver Secure $4,500/$35/$70/$600, the Personal Choice PPO Gold HSA-25

$2,600/80% and the Personal Choice PPO Silver Classic $4,750/$50/$100/90%. It should be noted that all

of those plans are richer than the Personal Choice PPO Bronze HSA-0 $6,750/100% from a benefit

standpoint, and that is why they have higher premiums than the Personal Choice PPO Bronze HSA-0

$6,750/100%, because they have a higher pricing AV, but they have a lower induced demand expectation.

7. Regarding your response to item 19 of our previous objections, were the same non-EHB benefits

in your plans during the experience period? If so, please explain why 1.01 is a reasonable estimate

of the impact of non-EHB benefits given that there were no non-EHB claims during the experience

period according to Table 2. Also you did not respond to the part of item 19 that asked how the

adjustments in the PAAM Table 10 were developed. Please include this in your response.

We have updated Table 2 to show the non-EHB in the experience period.

8. Please provide responses to items 20.b,20.c, 31, and 32 of our previous objections.

Please see the response to question 8 for the response to 20 b., 20 c.

Regarding questions 31 and 32, We do not have this data readily available at the level that is being

requested, therefore we are unable to provide a response to these two questions. We also view this data as

proprietary, and since the filing responses are made public, we think it would be inappropriate to provide

this information if it were readily available.

9. Your response to item 21 of our previous objections did not provide a quantitative development

or any explanation of how the 2.7% estimate for the health insurer fee was determined. Please

provide support for this estimate.

Please see the attached exhibits.

10. Regarding your response to item 22 of our previous objections, please explain how the Age

Calibration Factor reflects members with $0 premium due to the requirement to charge premium

for no more than three children.

The impact of members with $0 premium due to requirement to charge premium to no more than three

children is not included in the age calibration factor. We do not anticipate the percentage of children with

$0 premium increasing or decreasing, so there was no need to make an adjustment for this item.


The impact of $0 premium is about 0.9% we would have collected 0.9% more premium if children in

families with more than three children were required to pay premium. (Christa has confirmed that the

0.9% is still valid based on 2019 enrollment)

11. Where is the RA User Fee reflected in your response to item 24 of our previous objections?

We have updated this exhibit after we moved the RA user fee into taxes.

12. Table 6 of “2020_SmGrp_QCC_PAAMExhibits_061819.xlsm” shows taxes and fees totaling

5.87% including .03% for the RA User Fee. Cell E54 of Worksheet 2 of the URRT shows 5.84%.

Table 5 of “2020_SmGrp_KHPE_PAAMExhibits_061819.xlsm” shows Projected Risk Adjustment

PMPM of -$14.22, while cell D81 of Worksheet 2 of the URRT shows $0.18 less (i.e. -$14.40). This

suggests that the RA User Fee was included in risk adjustment in the URRT rather than in taxes

and fees. If so, please provide a corrected URRT.

We have updated the URRT.

13. Regarding your response to item 25 of our previous objections, please address the following:

a. The revised Actuarial Certification does not include a certification that the percent of

total premium that represents EHB included in Worksheet 2, Sections III and IV, was

calculated in accordance with actuarial standards of practice.

We have updated the actuarial certification.

b. The last sentence of the revised Actuarial Certification begins, “If an alternate

methodology was used to calculate the AV Metal Value for at least one plan offered ….”

Either alternate methodology was used or it was not. Also, it states, “a copy of the actuarial

certification required by 45 CFR Part 156, §156.135 will be included” when in fact it has

already been included in the initial filing. Please clarify the certification.

That statement is saying that some plans used an alternate methodology and some plans did not.

For the plans that used an alternate methodology we provided the required certification.

We have reworded that statement to say, “…when an alternate methodology was used to calculate

the AV metal value then a copy of the actuarial certification required by 45 CFR Part 156,

§156.135 was included.”

14. Your response to item 26 of our previous objections states that the requested data in Table 4,

Columns J and K of the PAAM exhibits was not provided last year but did not explain why it was

not provided this year. Please provide it or explain why this data is not available.

We do not have this data readily available at the level of detail requested, therefore we have not provided

it. Since the data at this level of detail is not used in the rate calculation it did not impact our MAIR. We

did provide the aggregate value of the pharmacy rebates in the experience period in table 2 as required,

and the value from table 2 is the value that impacts the MAIR.

15. As requested, you have added the RA User Fees in Table 6. Please confirm that there were no

offsetting adjustments made elsewhere, as this fee was not included in the initial submission.


We removed RA User Fee of $0.18 from the Projected Risk Adjustment PMPM in Table 5 as noted in our

response to question 20a of the June 18th objection letter.

16. In response to the Department’s RADV survey, issuers indicated that they did not include an

adjustment in the initial submission, as there was no supportable reason for a RADV adjustment in

the 2020 rate submission. Therefore, the Department has determined that there should be no

RADV adjustments in the 2020 rate filings; please modify the filing accordingly, if necessary.

As noted in the response to the last objection letter, we did not include any RADV adjustment in our

submission, therefore no change is required for this item.

17. If the risk adjustment results released on June 28, 2019 are inconsistent with your projected

assumptions, you may modify the risk adjustment transfer amount in Table 5. Supporting

documentation must be provided for all modifications. If such a modification is made, revise all the

documents and exhibits impacted and the PA Actuarial Memorandum to discuss this change. This

change must be made with your responses due by July 12, 2019.

We did not modify the risk adjustment transfer amount in Table 5 for QCC Small Group.

Original Response to #1 of June 18 Objection

QCC Small Group 2020 2019 ChangeChange in Morbidity 1.00 1.00 0.00%Taxes and Fees 5.84% 2.52% 3.32%Administrative Costs 14.65% 15.20% -0.55%Average Age Factor 1.512 1.494 1.25%Projected Allowed Claims 584.33$ $602.35 -2.99%Actual vs. Expected Experience 10.84%Rate Change 11.9%

Revised response to #1 of June 18 Objection

QCC Small Group 2020 2019 ChangeChange in Morbidity 1.00 1.00 0.00%Taxes and Fees 5.87% 2.52% 3.35%Administrative Costs 14.65% 15.20% -0.55%Average Age Factor 1.512 1.494 1.25%Residual Difference 1.30%Rate Change 5.3% <-- 1Q

#1 Rate Increase Drivers


QCC Small Group Allowed Claims Incurred ClaimsClaims processed through the claims system 437,743,313$ 363,459,821$ Claims processed outside of the company's claims system 7,221,961$ 7,221,961$ Incurred but not paid claims 5,756,494$

Revised Response to #6 of June 18 Objection

QCC Small Group Allowed Claims Incurred ClaimsClaims processed through the claims system 437,743,313$ 357,703,328$ Claims processed outside of the company's claims system 7,044,571$ 5,756,494$

Sub total 444,787,885$ 363,459,821$ Claims processed outside of the company's claims system 7,221,961$ 7,221,961$ Rx Rebates (10,202,730)$ (10,202,730)$

URRT Totals 441,807,115$ 360,479,052$

#2 Claims & IBNR

Total: 1.000 Total: 0.991 Total: 1.000 HIOS_ID Lives Induced Demand Lives Induced Demand Lives Induced Demand

31609PA0150025 8,483 1.174 7,498 1.174 7,498 1.184 31609PA0150026 13,298 1.131 12,004 1.131 12,004 1.142 31609PA0150027 13,511 0.979 13,795 0.979 13,795 0.988 31609PA0150028 1,783 1.058 1,741 1.058 1,741 1.068 31609PA0150029 2,060 0.915 2,451 0.915 2,451 0.923 31609PA0150030 1,227 1.028 1,030 1.028 1,030 1.038 31609PA0150031 4,891 0.949 1,240 0.949 1,240 0.958 31609PA0150032 2,022 1.100 2,023 1.100 2,023 1.110 31609PA0150033 114 0.793 106 0.793 106 0.800 31609PA0150034 1,298 0.873 1,064 0.873 1,064 0.881 31609PA0150035 2,471 0.968 1,848 0.968 1,848 0.977 31609PA0150036 6,222 0.805 7,585 0.805 7,585 0.813 31609PA0150037 4,694 0.862 4,128 0.862 4,128 0.870 31609PA0150039 865 1.011 793 1.011 793 1.021 31609PA0150047 2,770 1.008 3,627 1.008 3,627 1.017 31609PA0150048 1,262 0.778 1,406 0.778 1,406 0.785 31609PA0150049 2,060 0.815 2,724 0.815 2,724 0.823 31609PA0150050 2,271 0.968 5,833 0.968 5,833 0.977 31609PA0170001 121 0.895 696 0.895 696 0.903

Approved Annual 2019 Filing Updated MMs for 2020 Normalized for 2020

#5 Induced Utilization Factor

Filing1.184 1.142 0.988 1.068 0.923 1.038 0.958 1.110 0.800 0.881 0.977 0.813 0.870 1.021 1.017 0.785 0.823 0.977 0.903

Proposed 2020 Filing

#5 Induced Utilization Factor

Value from 8963 HIF % of Premium2015 11,881,321,294 2.01%2016 12,601,473,756 2.18%2018 13,728,845,558 2.30%

2020 Projection 2.71%

#9 HIF


Federal MLR =

QCC Small GroupProjected Claims PMPM (URRT) 515.06$ Premium PMPM (URRT) 664.49$ Quality Improvement Expense 0.80%Exchange User Fee & HIF 2.70%Federal Income Tax 1.14%Premium Tax 2.00%Federal MLR 83.2%

Revised Response to #24 of June 18 Objection

Federal MLR =<-- Per URRT Training: Risk Adj User fee moves from Risk Adj to Admin Cost

QCC Small Group513.30$ 662.46$

0.80%2.70%1.14%2.00%

Risk Adjustment User Fee 0.03%83.2%

(Projected Claims, after Risk Adjustment + Quality Improvement Expense - Risk Adj Prog User Fee) (Premium, before Risk Adjustment - HCR Taxes & Fees - Federal Income Tax - Premium Tax)

(Projected Claims, after Risk Adjustment + Quality Improvement Expense) (Premium, before Risk Adjustment - HCR Taxes & Fees - Federal Income Tax - Premium Tax - Risk Adj Prog User Fee)

Projected Claims, after Risk Adjustment

Federal MLR

Premium, before Risk AdjustmentQuality Improvement ExpenseExchange User Fee & HIFFederal Income TaxPremium Tax

#11 MLR Calculation

<-- Per URRT Training: Risk Adj User fee moves from Risk Adj to Admin Cost

#11 MLR Calculation

BlairCambria

HuntingdonWestmoreland

ClearfieldCentre

CumberlandLancaster

Lebanon

Dauphin

Schuylkill

Carbon

Cameron

York

Adams

Franklin

Juniata

Mifflin

Northumberland

Columbia

Montour

Luzerne

Lackawanna

Lehigh

DelawareFulton

Allegheny

Washington

Butler

Lawrence

Erie

Armstrong

Beaver

Bedford

Berks

Bradford

Bucks

Chester

Clarion Clinton

Crawford

Elk

Fayette

Forest

Greene

Indiana

Jefferson

Lycoming

Mckean

Mercer

Monroe

Montgomery

Northampton

Perry

Philadelphia

Pike

Potter

Snyder

Somerset

Sullivan

SusquehannaTioga

Union

Venango

Warren

Wayne

Wyoming

2019 and 2020 Service AreaIssuer: QCC Insurance Company

Market: Small Group

Key (modify as needed)

: On-exchange service area

: Off-exchange only service area

Completeness and Redaction Justification Checklist

SERFF ID: INAC-131927133

Redacted

(Y/N)

Page # in

Public PDF

Justification submitted

(Y/NA)

RFJ Part I - Unified Rate Review Template X

RFJ Part II – Consumer Friendly Justification X

RFJ Part III – Actuarial Memorandum X Y 61-68 Y

Federal Rates Template X

A.2.B. HIOS Submission X

A.2.C. SERFF Submission X

A.2.D. SERFF Rate/Rule Schedule Tab X

B. Cover Letter & PA Bulletin Information X

C. Rate Change Request Summary X

D.1.A. Company Information X Y 6 Y

D.1.B. Rate History & Proposed Variation in Rate Changes X N 7 N/A

D.1.C. Average Rate Change X N 7 N/A

Membership Count X N 7 N/A

PA Act. Exhibits Table 1 X N 14 N/A

D.1.E. Benefit Changes X N 7 N/A

Experience Period Claims & Premium X N 7-8 N/A


Credibility of Data X N 8 N/A

PA Act. Exhibits Tables 2b, 3b, 4b (if applicable) N/A N N/A N/A

Trend Identification X N 9 N/A


Historical Experience X N 9 N/A


Development of PAIR, MAIR and Total Allowed Claims X N 9-10 N/A


Retention Items X N 10-11 N/A


Normalized Market-Adjusted Projected Allowed Total Claims X N 11 N/A


Components of Rate Change X N 10-11 N/A



Plan Rate Development X N 11 N/A


Plan Premium Development for 21-Year-Old Non-Tobacco User X N 11 N/A


Age and Tobacco Factors X N 11 N/A


Geographic Factors X N 11 N/A


Network Factors X N 11 N/A


D.5.D. Service Area Composition N/A N N/A N/A

D.5.E. Composite Rating N/A N N/A N/A

D.6. Actuarial Certifications X Y 12 Y

Department Plan Design Summary & Rate Tables X N 20-55 N/A

Service Area Map X N 151 N/A

X YRedaction Justification (must be submitted if any information is redacted)

PA Actuarial Memorandum and Rate Exhibits

Federal Documents Required to Be Filed with PID

Summary Documents/Confirmation of HIOS & SERFF Submissions

Additional Exhibits

D.1.D.

D.5.B.

D.5.C.

A.2.

E.

D.2.C.

D.2.D.

D.3.

D.4.

D.5.A.

D.1.G.

Issuer Name: QCC Insurance Company, Inc.

Market: Small Group PPO

Redaction JustificationCompleted

(Mark with "X")TOC # Description

D.1.H.

D.1.I.

D.2.A.

D.2.B.

D.1.F.

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