Spreadsheet: e5533742-5f43-481e-8b32-68ceab193052
Sheet: A2. Rate Change & Enrollment

 |  | [NAME]Proposed Rate Change and Enrollment by Health Coverage Plan
[NAME]:
Plan Type(s):
Market Segment:
Rate Effective Date:
A | B | C | D | E | F |  | G | H | I |  | J | K | L |  | M | N |  | O | P
Plan Code or Name5 | Plan Type (HMO, POS, PPO, Indemnity, Other) | Carrier Plan Code or Name5 | Total Number of Members/Enrolled Policyholders + Covered Dependents1 | Total Number of Subscribers/Enrolled Policyholders1 | Total Number of Groups1 |  | Impacted Number of Members/Enrolled Policyholders + Covered Dependents2 | Impacted Number of Subscribers/Enrolled Policyholders2 | Impacted Number of Groups2 |  | Health Coverage Plan Rate PMPM in effect 12 months Prior to Rate Effective Date3, 4 | Health Coverage Plan Rate PMPM from Most Recently Approved Rate Filing Prior to Rate Effective Date3 | Proposed Health Coverage Plan Rate PMPM for Rate Effective Date3, 4 |  | Proposed Rate Change Compared to Prior 12 months4 | Proposed Rate Change Compared to Most Recently Approved Filing |  | % of Total Members/Enrolled Policyholders + Covered Dependents | % of Impacted Members/Enrolled Policyholders + Covered Dependents |  | Does the Annual Proposed Rate Change vary from the Average Annual Proposed rate change by more than 5 percentage points? | Is the difference between the Annual Proposed Rate Change  & the Average  more than 5 percentage points AND is the % of Impacted Members greater than 5%?
Totals
Totals weighted by Total Members/Enrolled Policyholders + Covered Dependents
Totals weighted by Impacted Members/Enrolled Policyholders + Covered Dependents
Standard HMO Plan Type | HMO
Standard POS Plan Type | POS
Standard PPO Plan Type | PPO
Standard Indemnity Plan Type | Indemnity
Standard "Other" Plan Type | Other
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
Plan 7
Plan 8
Plan 9
Plan 10
Plan 11
Plan 12
Plan 13
Plan 14
Plan 15
Plan 16
Plan 17
Plan 18
Plan 19
Plan 20
Plan 21
Plan 22
Plan 23
Plan 24
Plan 25
Plan 26
Plan 27
Plan 28
Plan 29
Plan 30
Plan 31
Plan 32
Plan 33
Plan 34
Plan 35
Plan 36
Plan 37
Plan 38
Plan 39
Plan 40
Plan 41
Plan 42
Plan 43
Plan 44
Plan 45
Plan 46
Plan 47
Plan 48
Plan 49
Plan 50
Plan 51
Plan 52
Plan 53
Plan 54
Plan 55
Plan 56
Plan 57
Plan 58
Plan 59
Plan 60
Plan 61
Plan 62
Plan 63
Plan 64
Plan 65
Plan 66
Plan 67
Plan 68
Plan 69
Plan 70
Plan 71
Plan 72
Plan 73
Plan 74
Plan 75
Plan 76
Plan 77
Plan 78
Plan 79
Plan 80
Plan 81
Plan 82
Plan 83
Plan 84
Plan 85
Plan 86
Plan 87
Plan 88
Plan 89
Plan 90
Plan 91
Plan 92
Plan 93
Plan 94
Plan 95
Plan 96
Plan 97
Plan 98
Plan 99
Plan 100
Plan 101
Plan 102
Plan 103
Plan 104
Plan 105
Plan 106
Plan 107
Plan 108
Plan 109
Plan 110
Plan 111
Plan 112
Plan 113
Plan 114
Plan 115
Plan 116
Plan 117
Plan 118
Plan 119
Plan 120
Plan 121
Plan 122
Plan 123
Plan 124
Plan 125
Plan 126
Plan 127
Plan 128
Plan 129
Plan 130
Plan 131
Plan 132
Plan 133
Plan 134
Plan 135
Plan 136
Plan 137
Plan 138
Plan 139
Plan 140
Plan 141
Plan 142
Plan 143
Plan 144
Plan 145
Plan 146
Plan 147
Plan 148
Plan 149
Plan 150
Plan 151
Plan 152
Plan 153
Plan 154
Plan 155
Plan 156
Plan 157
Plan 158
Plan 159
Plan 160
Plan 161
Plan 162
Plan 163
Plan 164
Plan 165
Plan 166
Plan 167
Plan 168
Plan 169
Plan 170
Plan 171
Plan 172
Plan 173
Plan 174
Plan 175
Plan 176
Plan 177
Plan 178
Plan 179
Plan 180
Plan 181
Plan 182
Plan 183
Plan 184
Plan 185
Plan 186
Plan 187
Plan 188
Plan 189
Plan 190
Plan 191
Plan 192
Plan 193
Plan 194
Plan 195
Plan 196
Plan 197
Plan 198
Plan 199
Plan 200
Plan 201
Plan 202
Plan 203
Plan 204
Plan 205
Plan 206
Plan 207
Plan 208
Plan 209
Plan 210
Plan 211
Plan 212
Plan 213
Plan 214
Plan 215
Plan 216
Plan 217
Plan 218
Plan 219
Plan 220
Plan 221
Plan 222
Plan 223
Plan 224
Plan 225
Plan 226
Plan 227
Plan 228
Plan 229
Plan 230
Plan 231
Plan 232
Plan 233
Plan 234
Plan 235
Plan 236
Plan 237
Plan 238
Plan 239
Plan 240
Plan 241
Plan 242
Plan 243
Plan 244
Plan 245
Plan 246
Plan 247
Plan 248
Plan 249
Plan 250
 |  |  | Notes: |  |  |  |  |  |  |  | Notes:
 |  |  | 1.  The Members, Subscribers and Groups counts by health coverage plan should be based on the total membership in New Hampshire for the market segment (Individual or Small Group) and product(s) being filed, regardless of renewal date. |  |  |  |  |  |  |  | 1.  The Members, Subscribers and Groups counts by health coverage plan should be based on the total membership in New Hampshire for the market segment (Individual or Small Group) and product(s) being filed, regardless of renewal date.
 |  |  | 2.  The impacted Members, Subscribers and Groups counts by health coverage plan should be based on the membership impacted by the proposed rate change in this filing.  This should be a subset of columns D-F. |  |  |  |  |  |  |  | 2.  The impacted Members, Subscribers and Groups counts by health coverage plan should be based on the membership impacted by the proposed rate change in this filing.  This should be a subset of columns D-F.
 |  |  | 3.  The Health Coverage Plan Rates should be normalized for rating factors.  The intent is for the NHID to be able to calculate final rates by utilizing the health plan coverage rate PMPM’s in this exhibit and all applicable rating factors, as described in the rating formula. |  |  |  |  |  |  |  | 3.  The Health Coverage Plan Rates should be normalized for rating factors.  The intent is for the NHID to be able to calculate final rates by utilizing the health plan coverage rate PMPM’s in this exhibit and all applicable rating factors, as described in the rating formula.
 |  |  | 4. The average proposed rate change (using impacted members) calculated in column M should equal  the reported requested weighted average rate change in SERFF.   Similarly the Prior Rate and Requested Rate Information in SERFF should correspond to rate information in column J and column L.  The carrier must explain any differences. |  |  |  |  |  |  |  | 4. The average proposed rate change (using impacted members) calculated in column M should equal  the reported requested weighted average rate change in SERFF.   Similarly the Prior Rate and Requested Rate Information in SERFF should correspond to rate information in column J and column L.  The carrier must explain any differences.
 |  |  | 5.  The carrier should provide a plan name or code for each health coverage plan in column C.  The carrier plan name or code in column C will correspond to an assigned plan index in column A.  We do not expect this plan index to change between rate filings. |  |  |  |  |  |  |  | 5.  The carrier should provide a plan name or code for each health coverage plan in column C.  The carrier plan name or code in column C will correspond to an assigned plan index in column A.  We do not expect this plan index to change between rate filings.