Spreadsheet: e5533742-5f43-481e-8b32-68ceab193052
Sheet: B1.Other Plan Design & Plan Rel

 |  | Exhibit B1:  Plan Design and Plan Relativity Factors (Other)
[NAME]:
Plan Type:6 | Other
Market Segment:
Rate Effective Date:
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
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Other Plan Type Information
Plan Code or Name5 | Carrier Plan Code or Name5 | Product | PCP Office Visit Copay1 | Specialist Office Visit Copay1 | [NAME] | Outpatient Surgery Copay1 | Inpatient Copay1 | In-Network Single Deductible | In-Network Coinsurance2 | In-Network Single OOP Max3 | Does  Deductible apply to all Medical Services?  (Y/N) | Note Services that Deductible does not apply to. | Does  Deductible apply to Pharmacy Services? (Y/N) | Are Preventive Services Covered 100%? (Y/N) | Does this health coverage plan provide for coverage for MH/SA? (Y/N) | Does this health coverage plan have a [NAME] component? (Y/N) | Retail Pharmacy Single Deductible Generic | Retail Pharmacy Single Deductible Brand Formulary | Retail Pharmacy Single Deductible Brand Non-Formulary | [NAME] [NAME] | Retail Pharmacy Copay Brand Formulary | Retail Pharmacy Copay Brand Non-Formulary |  | Number of Members from Most Recent Time Period Available | Impacted Number of Members from Most Recent Time Period Available | % of Impacted Members |  | Plan Relativity Factors for Proposed Rates4 | Plan Relativity Factors from the 12 months Prior4 |  | Change in Plan Relativity Factor | Have there been any changes in the benefits or cost sharing for this plan in the prior 12 months? (Y/N) |  | Policy Form Number | Is this health coverage plan open or closed? (Y/N) | Is this health coverage plan plan Grandfathered or Non-Grandfathered per the ACA definition? | Renewability of the Plan | General Marketing Method | Issue Age Limits | Is this a new health coverage plan? (Y/N) | If the "Change in Plan Relativity Factor" is more than 5%, please provide actuarial justification.  If there have been changes in the benefits for this plan in the prior 12 months, please also indicate what has changed. |  | Does the Annual Benefit Level Rate Adjustment change by more than 5 percentage points from the prior period? | Does the Annual Benefit Level Rate Adjustment change by more than 5 percentage points AND is the % of Impacted Members greater than 5%?
Total
Standard Health Coverage Plan |  | Other
Plan 1 |  | Other
Plan 2 |  | Other
Plan 3 |  | Other
Plan 4 |  | Other
Plan 5 |  | Other
Plan 6 |  | Other
Plan 7 |  | Other
Plan 8 |  | Other
Plan 9 |  | Other
Plan 10 |  | Other
Plan 11 |  | Other
Plan 12 |  | Other
Plan 13 |  | Other
Plan 14 |  | Other
Plan 15 |  | Other
Plan 16 |  | Other
Plan 17 |  | Other
Plan 18 |  | Other
Plan 19 |  | Other
Plan 20 |  | Other
Plan 21 |  | Other
Plan 22 |  | Other
Plan 23 |  | Other
Plan 24 |  | Other
Plan 25 |  | Other
Plan 26 |  | Other
Plan 27 |  | Other
Plan 28 |  | Other
Plan 29 |  | Other
Plan 30 |  | Other
Plan 31 |  | Other
Plan 32 |  | Other
Plan 33 |  | Other
Plan 34 |  | Other
Plan 35 |  | Other
Plan 36 |  | Other
Plan 37 |  | Other
Plan 38 |  | Other
Plan 39 |  | Other
Plan 40 |  | Other
Plan 41 |  | Other
Plan 42 |  | Other
Plan 43 |  | Other
Plan 44 |  | Other
Plan 45 |  | Other
Plan 46 |  | Other
Plan 47 |  | Other
Plan 48 |  | Other
Plan 49 |  | Other
Plan 50 |  | Other
 |  | Notes: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Notes:
 |  | 1. For [NAME] products, provide cost sharing for most utilized tier. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1. For [NAME] products, provide cost sharing for most utilized tier.
 |  | 2.  Coinsurance should reflect the member's portion. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 2.  Coinsurance should reflect the member's portion.
 |  | 3. The OOP [NAME] should include the deductible. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3. The OOP [NAME] should include the deductible.
 |  | 4. The Plan Relativity Factor should not reflect any differences in the retention by health coverage plan. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 4. The Plan Relativity Factor should not reflect any differences in the retention by health coverage plan.
 |  | 5.  Plan relativity factors for each health coverage plan should be provided.  This list should be consistent with the list provided in [NAME]. The plan design information should reflect the benefits in place as of the rate effective date.  The carrier should provide a plan name or code for each health coverage plan in column B.  The carrier plan name or code in column B will correspond to an assigned plan index in column A.  We do not expect this plan index to change between rate filings. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 5.  Plan relativity factors for each health coverage plan should be provided.  This list should be consistent with the list provided in [NAME]. The plan design information should reflect the benefits in place as of the rate effective date.  The carrier should provide a plan name or code for each health coverage plan in column B.  The carrier plan name or code in column B will correspond to an assigned plan index in column A.  We do not expect this plan index to change between rate filings.
 |  | 6.  A separate Exhibit B1 should be completed for each plan type included in the filing |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 6.  A separate Exhibit B1 should be completed for each plan type included in the filing