serff tracking #: state tracking #: company tracking ... · for your approval, anthem blue cross...

Filing at a Glance Company: Anthem Health Plans, Inc dba Anthem Blue Cross and Blue Shield of Connecticut

Product Name: Individual 2016

State: Connecticut

TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)

Sub-TOI: HOrg02I.005C Individual - Other

Filing Type: Rate

Date Submitted: 04/30/2015

SERFF Tr Num: AWLP-130050273

SERFF Status: Assigned

State Tr Num: 201503007

State Status:

Co Tr Num:

ImplementationDate Requested:

01/01/2016

Author(s): John Bryson, Michael Bears, Dickson Lee, Katie Wondergem, Matt Lindsey

Reviewer(s): Paul Lombardo (primary)

Disposition Date:

Disposition Status:

Implementation Date:

SERFF Tracking #: AWLP-130050273 State Tracking #: 201503007 Company Tracking #:

State: Connecticut Filing Company: Anthem Health Plans, Inc dba Anthem Blue Crossand Blue Shield of Connecticut

TOI/Sub-TOI: HOrg02I Individual Health Organizations - Health Maintenance (HMO)/HOrg02I.005C Individual - Other


Project Name/Number: /

PDF Pipeline for SERFF Tracking Number AWLP-130050273 Generated 05/06/2015 06:40 AM

General Information

Project Name: Status of Filing in Domicile: Not Filed

Project Number: Date Approved in Domicile:

Requested Filing Mode: Review & Approval Domicile Status Comments:

Explanation for Combination/Other: Market Type: Individual

Submission Type: New Submission Individual Market Type: Individual

Overall Rate Impact: 6.7% Filing Status Changed: 05/01/2015

State Status Changed:

Deemer Date: Created By: John Bryson

Submitted By: John Bryson Corresponding Filing Tracking Number:

PPACA: Not PPACA-Related

PPACA Notes: null

Exchange Intentions: This filing contains benefit plans to be sold through the CTExchange and benefit plans to be sold Off the CT Exchange

Filing Description:

April 30, 2015

Mr. Paul Lombardo, ASA, MAAAActuary, Life & Health DivisionState of Connecticut Insurance DepartmentP.O. Box 816Hartford, CT 06142-0816

Re: Anthem BCBS 2016 Individual Rate FilingSERFF Tracking Number AWLP-130050273

Dear Mr. Lombardo:

For your approval, Anthem Blue Cross and Blue Shield (ABCBS) is submitting proposed premium rates for its new andrenewing Individual Products for both On & Off the Connecticut Exchange, effective January 1, 2016.

Please see the enclosed files for the scope of changes and the supporting documents:

•Anthem Individual State - Actuarial Memorandum•Anthem 2016 Actuarial Certification•Anthem Individual Federal – Actuarial Memorandum•Anthem 2016 Unified Rate Review Template•Unique Plan Design Supporting Documentation•Actuarial Value Screenshot for each Individual Product•Anthem 2016 Rates Template•Anthem 2016 Summary of Benefits







Company and Contact

Filing Fees

All Individual products include pediatric dental benefits embedded in the benefits.

The individual rates are developed from the 2014 Individual ACA experience and this same experience data is used for theClaim Lag Triangle exhibit.

This filing includes estimates for the impact of risk adjustment based on input from Wakely Consulting. Anthem plans to adjustthis filing if the results of the June update to those estimates are materially different. Anthem also plans to submit adjustmentsto this filing if the final MOOP guidance differs from the current MOOP guidance.

Thank you for your attention to this filing. If you have any questions regarding this matter, please feel free to contact me at 203677-8026. You may also email me at [email protected].

Sincerely,

John Bryson, ASA, MAAADirector and Actuary 1

Attachments

Filing Contact InformationJohn Bryson, Actuarial Dir [email protected]

370 Bassett Road

North Haven, CT 06473

203-239-8249 [Phone]

Filing Company InformationAnthem Health Plans, Inc dbaAnthem Blue Cross and BlueShield of Connecticut

108 Leigus Road

Wallingford, CT 06492

(203) 677-4000 ext. [Phone]

CoCode: 60217

Group Code: 671

Group Name: WellPoint Inc Group

FEIN Number: 06-1475928

State of Domicile: Connecticut

Company Type: Life,Accident, Health

State ID Number:

Fee Required? No

Retaliatory? No

Fee Explanation:







Rate Information Rate data applies to filing.

Filing Method: Review & Approval

Rate Change Type: Increase

Overall Percentage of Last Rate Revision: 0.100%

Effective Date of Last Rate Revision: 01/01/2015

Filing Method of Last Filing: Review & Approval

Company Rate Information

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Number of Policy

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Anthem Health Plans,Inc dba Anthem BlueCross and BlueShield of Connecticut

Increase 6.700% 6.700% % %


State: Connecticut Filing Company: Anthem Health Plans, Inc dba Anthem Blue Cross and Blue Shieldof Connecticut





Rate Review Detail

COMPANY:Company Name: Anthem Health Plans, Inc dba Anthem Blue Cross and Blue Shield of Connecticut

HHS Issuer Id: 86545

PRODUCTS:

Product Name HIOS Product ID HIOS Submission ID Number of Covered

LivesSee Actuarial Memorandum Exhibit I 55000

Trend Factors: 7.6%

FORMS:New Policy Forms: HIX_CT_HMO_HSA_(1/16), CT_OFF_HIX_HM_HS_(1/16), CT_HIX_PP_HS_(1/16),

CT_OFF_HIX_PP_HS_(1/16)

Affected Forms:

Other Affected Forms:

REQUESTED RATE CHANGE INFORMATION:Change Period: Annual

Member Months: 660,000

Benefit Change: Increase

Percent Change Requested: Min: 3.6 Max: 11.1 Avg: 6.7

PRIOR RATE:Total Earned Premium: 356,375,873.00

Total Incurred Claims: 278,849,326.00

Annual $: Min: 82.90 Max: 1,205.30 Avg: 448.60

REQUESTED RATE:Projected Earned Premium: 324,090,843.00

Projected Incurred Claims: 258,803,691.00

Annual $: Min: 88.80 Max: 1,271.50 Avg: 491.10







Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Actuarial memorandum ExhibitI

HIX_CT_HMO_HSA_(1/16),CT_OFF_HIX_HM_HS_(1/16),CT_HIX_PP_HS_(1/16),CT_OFF_HIX_PP_HS_(1/16)

New 2016 ActuarialMemorandum - CT INDExhibit I.pdf,







1

HIOS Plan Name 2016 HIOS Plan IDOn/Off

Exchange Metal Level Network NameArea(s) Offered

2015 HIOS Plan ID Mapping

Plan Specific Rate Increase

(excluding aging) {1}

Catastrophic HMO Pathway X Enhanced 86545CT1230005 On Catastrophic CT IND:-:Pathway X Enhanced All 86545CT1230005 7.04%Bronze HMO Pathway X Enhanced for HSA 86545CT1230001 On Bronze CT IND:-:Pathway X Enhanced All 86545CT1230001 11.08%Bronze HMO Pathway X Enhanced 86545CT1230002 On Bronze CT IND:-:Pathway X Enhanced All 86545CT1230002 4.72%Gold HMO Pathway X Enhanced 86545CT1230004 On Gold CT IND:-:Pathway X Enhanced All 86545CT1230004 4.60%Anthem HMO Catastrophic BlueCare 6850/0% 86545CT1310033 Off Catastrophic CT IND:-:BlueCare All 86545CT1310033 7.02%Anthem Bronze HMO BlueCare 6000/12000/0% for HSA 86545CT1310019 Off Bronze CT IND:-:BlueCare All 86545CT1310019 9.38%Anthem Bronze HMO BlueCare 6000/0% 86545CT1310024 Off Bronze CT IND:-:BlueCare All 86545CT1310024 5.09%Anthem Bronze HMO BlueCare 6550/13100/0% for HSA 86545CT1310039 Off Bronze CT IND:-:BlueCare All NONE n/aAnthem Silver HMO BlueCare 3500/7000/0% for HSA 86545CT1310030 Off Silver CT IND:-:BlueCare All 86545CT1310030 4.93%Anthem Silver HMO BlueCare 3500/0% 86545CT1310031 Off Silver CT IND:-:BlueCare All 86545CT1310031 5.46%Anthem Silver HMO BlueCare Tiered 3000/3850/0% 86545CT1310040 Off Silver CT IND:-:BlueCare All NONE n/aAnthem Gold HMO BlueCare 1500/0% 86545CT1310032 Off Gold CT IND:-:BlueCare All 86545CT1310032 4.60%Anthem Gold HMO Pathway X Enhanced 1850/0% 86545CT1310035 Off Gold CT IND:-:Pathway X Enhanced All 86545CT1340009 4.14%Anthem Gold HMO BlueCare Tiered 2000/3500/0% 86545CT1310043 Off Gold CT IND:-:BlueCare All NONE n/aBronze PPO Standard Pathway X 86545CT1330002 On Bronze CT IND:-:Pathway X All 86545CT1330002 10.05%Bronze PPO Standard Pathway X for HSA 86545CT1330009 On Bronze CT IND:-:Pathway X All 86545CT1330009 3.64%Silver PPO Standard Pathway X 86545CT1330001 On Silver CT IND:-:Pathway X All 86545CT1330001 5.50%Silver PPO Pathway X 86545CT1330004 On Silver CT IND:-:Pathway X All 86545CT1330004 6.83%Gold PPO Standard Pathway X 86545CT1330003 On Gold CT IND:-:Pathway X All 86545CT1330003 9.18%Anthem Bronze PPO Century Preferred 5700/11400/20% for 86545CT1340005 Off Bronze CT IND:-:Century Preferred All 86545CT1340005 11.10%Anthem Bronze PPO Century Preferred 6850/0% 86545CT1340010 Off Bronze CT IND:-:Century Preferred All NONE n/aAnthem Silver PPO Century Preferred 2750/20% 86545CT1340006 Off Silver CT IND:-:Century Preferred All 86545CT1340006 7.57%Anthem Silver PPO Century Preferred 2500/20% 86545CT1340007 Off Silver CT IND:-:Century Preferred All 86545CT1340007 7.59%Anthem Silver PPO Century Preferred 3000/6000/20% for HS 86545CT1340011 Off Silver CT IND:-:Century Preferred All NONE n/aAnthem Silver PPO Century Preferred 3500/7000/10% 86545CT1340014 Off Silver CT IND:-:Century Preferred All NONE n/aAnthem Silver PPO Century Preferred Tiered 2850/4000/0% 86545CT1340015 Off Silver CT IND:-:Century Preferred All NONE n/aAnthem Gold PPO Century Preferred 1500/3000/20% for HSA 86545CT1340012 Off Gold CT IND:-:Century Preferred All NONE n/aAnthem Gold PPO Century Preferred 1750/0% 86545CT1340013 Off Gold CT IND:-:Century Preferred All NONE n/aAnthem Gold PPO Century Preferred Tiered 1750/3250/0% 86545CT1340016 Off Gold CT IND:-:Century Preferred All NONE n/aGold HMO Pathway X Enhanced, a Multi-State Plan 86545CT1470002 On Gold CT IND:-:Pathway X Enhanced All 86545CT1470002 4.14%Silver PPO Pathway X, a Multi-State Plan 86545CT1480002 On Silver CT IND:-:Pathway X All 86545CT1480002 6.82%

Notes:

{1} Plan level increases in rates do not include demographic changes in the population.

Exhibit I - Non-Grandfathered Rate Changes

Anthem Health Plans, Inc.Individual

Rates Effective January 1, 2016

Supporting Document Schedules Satisfied - Item: Actuarial MemorandumComments:Attachment(s): 2016 Actuarial Memorandum - CT IND State (4-30-2015).pdfItem Status:Status Date:

Bypassed - Item: Consumer Disclosure FormBypass Reason: Not needed at this timeAttachment(s):Item Status:Status Date:

Satisfied - Item: Actuarial Memorandum and CertificationsComments:

Attachment(s): Anthem Actuarial Certification.pdf2016 Actuarial Memorandum - CT IND Federal (4-30-2015).pdf

Item Status:Status Date:

Satisfied - Item: Unified Rate Review TemplateComments:Attachment(s): URRT - CT - IND1 - 86545 - Submission 04 29 2015.pdfItem Status:Status Date:

Satisfied - Item: AV ScreenshotsComments:Attachment(s): CT IND 2016 Plan AVs (4-30-15).pdfItem Status:Status Date:

Satisfied - Item: Unique Plan JustificationComments:Attachment(s): CT IND 2016 Unique Plan Justification Sets (4-30-15).pdfItem Status:







Status Date:

Satisfied - Item: Rate TemplatesComments:Attachment(s): 2016_CT_IND_On-Off_All-Plans_86545_RateTables.pdfItem Status:Status Date:

Satisfied - Item: Summary of BenefitsComments:Attachment(s): CT IND 2016 Summary of Benefits (4-30-15).pdfItem Status:Status Date:







CT_OFF_HIX_PP_HS_(1/16)3. Introduction

This filing includes product average rate increase of 6.7% with range by product between 4.1% and 10.1%, and by plan from 3.6% to 11.1%. More details are provided below in Section 4: Proposed Rate Increase.

Emerging single risk pool experience has been used to develop the current rates, while previous rates were developed assigning full credibility to the manual rates.

Area factors remain the same as 2015. Refer to Exhibit K: Area Factors.

The purpose of this rate filing is to establish rates that are reasonable relative to the benefits provided and to demonstrate compliance with state laws and provisions of the Affordable Care Act (ACA). The rates will be in-force for effective dates on or after January 1, 2016. These rates will apply to plans offered both On-Exchange and Off-Exchange. This rate filing is not intended to be used for other purposes.

Policy Form Number(s):HIX_CT_HMO_HSA_(1/16)CT_OFF_HIX_HM_HS_(1/16)CT_HIX_PP_HS_(1/16)

Primary Contact Telephone Number: (203) 677-8026Primary Contact Email Address: [email protected]

2. Scope and Purpose of the Filing

This filing for Anthem Health Plans, Inc., also referred to as Anthem, complies with the most recent regulations and related guidance. To the extent relevant rules or guidance on the rules are updated or changed, amendments to this filing may be required.

Market: IndividualEffective Date: January 1, 2016

• Company Contact InformationPrimary Contact Name: John Bryson

State: ConnecticutHIOS Issuer ID: 86545NAIC Company Code: 60217

ACTUARIAL MEMORANDUM

1. General Information

• Company Identifying InformationCompany Legal Name: Anthem Health Plans, Inc.

• Allowed and Incurred Claims Incurred During the Experience Period

The allowed claims are determined by subtracting non-covered benefits, provider discounts, and coordination of benefits amounts from the billed amount.

These rate changes by plan are shown in Exhibit I: Non-Grandfathered Rate Changes.

5. Experience Period Premium and Claims

Experience shown in Worksheet 1, Section I of the Unified Rate Review Template is for Connecticut Individual non-grandfathered, single risk pool compliant policies. The information shown is for the identified legal entity only.

Claims experience in Worksheet 1, Section I of the Unified Rate Review Template reflects dates of service from January 1, 2014 through December 31, 2014.

• Paid Through Date

Claims shown in Worksheet 1, Section I of the Unified Rate Review Template are paid through March 31, 2015.

Anticipated changes due to network contracting.

Although rates are based on the same experience, proposed rate changes vary by plan from 3.6% to 11.1%. Factors that affect the variation in the proposed rate changes by plan include:

Changes in benefit design that vary by plan

Updated measurement of relative benefits between plans

Changes in the adjustment factor for Catastrophic eligibility

Changes in Non-Benefit Expenses that are applied on a PMPM basis

Factors that affect the proposed rate change for all plans include:

Lower claims cost in the experience: We have included emerging 2014 ACA experience in the rate development.

Medical Trend: The underlying claim costs are expected to increase year over year due to inflation, advancing medical technology and techniques, and increased utilization and cost-shifting.

Morbidity: There are anticipated changes in the market-wide morbidity of the covered population in the projection period.

Benefit modifications and plan design changes.

Changes in taxes, fees, and non-benefit expenses. These include changes in payments from and contributions to the Federal Transitional Reinsurance Program.

4. Proposed Rate Increase

Consistency with most recent financial statements

Inpatient Hospital: Includes non-capitated facility services for medical, surgical, maternity, mental health and substance abuse, skilled nursing, and other services provided in an inpatient facility setting and billed by the facility.

The estimated Non-Grandfathered gross earned premium for Connecticut Individual is $286,373,832, where earned premium is the pro-rata share of premium owed to Anthem due to subscribers actively purchasing insurance coverage during the experience period.

The preliminary MLR Rebate estimate is $0, which is consistent with the December 31, 2014 Anthem general ledger estimate allocated to the Non-Grandfathered portion of Individual. Note that this is an estimate and will not be final until 7/31/2015. Using this MLR estimate, the net earned premium for Connecticut Individual is $286,373,832 as shown in cell F14 of Worksheet 1, Section I of the Unified Rate Review Template.

Exhibit S: Historical Experience details historical experience for the policy forms included in this filing.

Anthem reconciles its internal source systems monthly to ensure consistency with reported financials. Please note that the products contained in this filing are only a part of the total business reported on the financial statements. In addition, there are timing differences and certain definitional differences in the statutory statements compared to emerging experience utilized in this filing.

6. Benefit Categories

The methodology used to determine benefit categories in Worksheet 1, Section II of the Unified Rate Review Template is as follows:

Allowed and incurred claims are completed using the chain ladder method, an industry standard, by using historic paid vs. incurred claims patterns. The method calculates historic completion percentages, representing the percent of claims paid for a particular month after one month of run out, two months, etc. Claim backlog files are reviewed on a monthly basis and are accounted for in the historical completion factor estimates.

Allowed and incurred claims shown in Worksheet 1, Section I of the Unified Rate Review Template are $343,235,845 and $261,173,649, respectively. These amounts differ from those shown in Exhibit B: Claims Experience for Rate Developments due to the Unified Rate Review Template taking Non-ACA plans and Rx Rebates into account.

Additional information can be found on Exhibit B: Claims Experience for Rate Developments.

• Premiums (net of MLR Rebate) in Experience Period

Individuals losing employer coverage

Individuals converting from Anthem Non-ACA policies

Individuals electing to drop coverage

The movement assumptions above are based on market research and assumptions on the retention and sales rates. The morbidity impacts of population movement are based on health status determined from internal risk score data.

Pent-up demand adjustment: As previously uninsured individuals obtained insurance in 2014, Anthem expected them to have some pent-up demand for health care services in year one. This pent-up demand impact is captured in our 2014 experience and Anthem does not expect this additional utilization to continue in 2016. Therefore, an adjustment has been made to back-out the additional utilization in 2014 that was attributed to pent-up demand.

7. Projection Factors

The experience in Worksheet 1, Section I of the Unified Rate Review Template is brought into the projection period using the factors described below.

• Changes in the Morbidity of the Population Insured

Morbidity changes include the following (for Morbidity factor, see Exhibit D: Projection Period Adjustments):

Individuals no longer qualifying for Medicaid

Higher morbidity of the uninsured compared to the insured population: This adjustment is based on a CDC study on the health status and life styles of both currently insured and uninsured populations. This adjustment also considers the expected number of previously uninsured individuals expected to move into the Individual market in 2016.

Outpatient Hospital: Includes non-capitated facility services for surgery, emergency room, lab, radiology, therapy, observation and other services provided in an outpatient facility setting and billed by the facility.

Professional: Includes non-capitated primary care, specialist, therapy, the professional component of laboratory and radiology, and other professional services, other than hospital-based professionals whose payments are included in facility fees.

Other Medical: Includes non-capitated ambulance, home health care, DME, prosthetics, supplies, vision exams, and dental services.

Capitation: Includes all services provided under one or more capitated arrangements.

Prescription Drug: Includes drugs dispensed by a pharmacy and rebates received from drug manufacturers.

Area/Network: The area claims factors are developed based on an analysis of Individual allowed claims by network, mapped to the prescribed 2016 rating areas using the subscriber's 5-digit zip code.

Benefit Plan: The experience period claims are normalized to an average 2016 plan using benefit relativities. The benefit relativities include the value of cost shares and anticipated changes in utilization due to the difference in average cost share requirements.

• Other Adjustments

For members active less than 12 months of the experience period, claims were adjusted using company specific seasonality and maturation factors.

The impact of this analysis is reflected in the "Seasonality" adjustment factor of 1.0068 shown in line 2 of Exhibit A: Market Adjusted Index Rate Development.

• Changes in Benefits

Benefit changes include the following:

Rx Adjustments: The claims are adjusted for differences in the Rx formulary and the impact of moving drugs into different tiers in the projection period relative to what is reflected in the base experience data as shown in Exhibit D: Projection Period Adjustments.

• Changes in Demographics

The experience data was normalized to reflect anticipated changes in age/gender, area, network, and benefit plan from the experience period to the projection period. The purpose of these factors is to adjust current experience to be reflective of expected claim experience in the projection period. See Section 22: Membership Projections for additional information on membership movement. The normalization factors and their aggregate impact on the underlying experience data are detailed in Exhibit C: Normalization Factors.

Age/Gender: The assumed claims cost is applied by age and gender to the experience period distribution and the projection period distribution.

Our goal is to price to the average risk of the 2016 ACA market. Since Anthem-specific experience was used as a starting point, we adjusted this experience to be more consistent with the overall market in Connecticut. Wakely Consulting collected demographic and risk information from carriers, and calculated Anthem's relative risk to the market for 2014. We have adjusted our starting experience using the results of that survey, as shown in line item 4 of Exhibit A: Market Adjusted Index Rate Development.

The annual pricing trend used in the development of the rates is 7.6%. The trend is developed by normalizing historical Small Group benefit expense for changes in the underlying population and known cost drivers, which are then projected forward to develop the pricing trend. Examples of such changes include contracting, cost of care initiatives, workdays, costs associated with Hepatitis C, compound drugs, average wholesale price, and expected introduction of generic drugs. Small Group benefit expense was used as the basis for the Individual trend development because there is not enough historical Individual ACA data to develop a credible trend analysis. The trend includes a volatility provision in accordance with Actuarial Standards of Practice. The claims are trended 23.6 months from the midpoint of the experience period, which is July 12, 2014, to the midpoint of the projection period, which is July 1, 2016. The mid-point of the experience period is shifted later than July 1, 2014 due to staggered open enrollment in 2014. Additional information can be found in Exhibit D: Projection Period Adjustments.

Projected trends include the estimated cost of the pharmaceutical Sovaldi and other high-cost drugs for treating Hepatitis C. These cost estimates were based on claims experience, together with CDC recommendations, Industry and Anthem Inc. data.

Grace Period: The base period experience may be adjusted upward to account for some incidence of enrollees not paying premiums due during the first month of the 90-day grace period when the QHP is liable for paying claims. Based on 2014 experience this adjustment is 1.0024.

Change in Medical Management: medical management savings not already included in the claims experience and trend.

Change in Provider Contracts: anticipated changes in provider contracts are reflected in the plan level adjustments and the region rating factors.

The cost of pediatric dental and vision benefits are included, as can be found in Exhibit E: Other Claim Adjustments.

Rx Rebates: The projected claims cost is adjusted to reflect anticipated Rx rebates. These projections take into account the most up-to-date information regarding anticipated rebate contracts, drug prices, anticipated price inflation, and upcoming patent expirations.

• Trend Factors (cost/utilization)

Induced Demand Due to Cost Share Reductions: Individuals below 250% Federal Poverty Level who enroll in silver plans On-Exchange will be eligible for cost share reductions. The base period experience has higher anticipated utilization built-in as CSR plans were made available in 2014. As a result, the 2016 utilization impact is calculated based on the projected change in silver plans On-Exchange membership. Anthem used the HHS-promulgated factors for the Induced Demand Utilization factors.

11. Risk Adjustment and Reinsurance

• Experience Period Risk Adjustment and Reinsurance

Wakely Consulting collected demographic and risk information from carriers, and calculated Anthem's relative risk to the market for 2014. Experience period risk adjustment transfers were based on the results of that survey.

Experience period reinsurance recoveries were based on expected recoveries as of December 31, 2014, plus PPIA that was recognized through March 2015.

• Projected Risk Adjustments

The Risk Adjustment program transfers funds from lower risk plans to higher risk plans in the Non-Grandfathered Individual and Small Group market. The HHS operated Risk Adjustment program is supported by a user fee, as shown in Exhibit F: Risk Adjustment and Reinsurance - Contributions and Payments.

Based on an analysis of historical data, the standard for fully credible experience is 6,277 members.

To determine credibility, the following formula was used:

• Resulting Credibility Level Assigned to Base Period Experience

With 43,931 members, the credibility level assigned to the experience in Worksheet 1, Section II of the Unified Rate Review Template is 100%.

10. Paid to Allowed Ratio

The ‘Paid to Allowed Average Factor in Projection Period’ shown in Worksheet 1, Section III of the Unified Rate Review Template is developed by membership-weighted essential health benefit paid claims divided by membership-weighted essential health benefit allowed claims of each plan. The projected membership by plan is shown in Worksheet 2, Section II of the Unified Rate Review Template.

8. Credibility Manual Rate Development

Anthem is assigning 100% credibility to the single risk pool experience. Therefore, a manual rate was not required in the development of these rates.

9. Credibility of Experience

• Description of the Credibility Method Used

�𝐸𝑥𝑝𝑒𝑟𝑖𝑒𝑛𝑐𝑒 𝑃𝑒𝑟𝑖𝑜𝑑 𝑀𝑒𝑚𝑏𝑒𝑟𝑠

6,277

• Administrative Expense

Administrative Expense contains both acquisition costs associated with the production of new business through non-broker distribution channels (direct, telesales, etc) as well as maintenance costs associated with ongoing costs for the administration of the business. Acquisition costs are projected using historical cost per member sold amounts applied to future sales estimates. Maintenance costs are projected for 2016 based on 2014 actual expenses, with adjustments for expected changes in business operations including new expenses for risk management, regulatory compliance and premium reconciliation and balancing.

• Miscellaneous Item

The miscellaneous items represent DOI fees and assements, including the assessment from the State of Connecticut to cover the cost of the Vaccine Immunization Program which provides immunizations for all Connecticut residents.

• Quality Improvement Expense

The quality improvement expense represents Anthem's dedication to providing the highest standard of customer care and consistently seeking to improve health care quality, outcomes and value in a cost efficient manner.

Anthem is assuming a risk transfer payment of ($0.43), as shown in Exhibit F: Risk Adjustment and Reinsurance - Contributions and Payments.

• Projected ACA Reinsurance Recoveries Net of Reinsurance Premium

The transitional reinsurance risk mitigation program collects funds from all insurance issuers and TPAs and redistributes them to high cost claimants in the Non-Grandfathered Individual market. The reinsurance contribution is equal to the national per capita reinsurance contribution rate as shown in Exhibit F: Risk Adjustment and Reinsurance - Contributions and Payments.

The reinsurance payment is developed using actual 2014 reinsurance experience, projected paid claims, claim probability distribution, and reinsurance payment guidelines. The claim probability distribution observes claims between $90,000 and $250,000 using a claim probability distribution that reflects the anticipated claim cost distribution of the 2016 Individual market. The coinsurance rate is 50%. Expected paid claims are calculated for an assumed average On-Exchange plan design. Reinsurance payments are allocated proportionally by plan premiums to all plans in the risk pool.

12. Non-Benefit Expenses, Profit and Risk

Non-Benefit expenses are detailed in Exhibit G: Non-Benefit Expenses and Profit & Risk.

Exchange Fee: The Exchange User Fee applies to Exchange business only, but the cost is spread across all Individual plans. The expected charge is estimated at 1.35% of Total Individual Premium. The resulting fee/percentage is applied evenly to all plans in the risk pool, both On and Off Exchange.

Premium taxes, federal income taxes, and state income taxes are also included in the retention items.

• Profit

Profit is reflected on a post-tax basis as a percent that does not vary by product or plan. The profit percentage does not include any assumed risk corridor payments or receipts.

13. Projected Loss Ratio

• Projected Federal MLR

The QI Expense assumptions are based on historical amounts related to the following initiatives: Improve Health Outcomes, Activities to Prevent Hospital Readmissions, Improve Patient Safety and Reduce Medical Errors, Wellness and Health Promotion Activities, HIT Expenses for Health Care Quality Improvements, and ICD-10.

• Selling Expense

Selling Expense represents broker commissions and bonuses associated with the broker distribution channel using historical and projected commission levels. Commissions will be paid both On-Exchange and Off-Exchange.

• Taxes and Fees

Patient-Centered Outcomes Research Institute (PCORI) Fee: The PCORI fee is a federally-mandated fee designed to help fund the Patient-Centered Outcomes Research Trust Fund. For plan years ending on or after October 1, 2014, and before October 1, 2015, the fee is $2.08 per member per year. Thereafter, for every plan year ending before October 1, 2019, the fee will increase by the percentage increase in National Healthcare Expenditures.

ACA Insurer Fee: The health insurance industry will be assessed a permanent fee, based on market share of net premium, which is not tax deductible. The tax impact of non-deductibility is captured in this fee.

• Projection Period Index Rate

The index rate represents the average allowed claims PMPM of essential health benefits for Anthem's Individual Non-Grandfathered Business. The projection period index rate was developed as shown in Exhibit A: Market Adjusted Index Rate Development by adjusting the projected incurred claims PMPM as described in Section 7: Projection Factors of this memorandum. Covered benefits in excess of essential health benefits that are included in the projection period allowed claims (cell V32 of Worksheet 1, Section II of the Unified Rate Review Template) are elective abortion. No benefits in excess of the essential health benefits are included Exhibit A: Market Adjusted Index Rate Development's projection period index rate (also shown in cell V44 of Worksheet 1, Section III of the Unified Rate Review Template).

16. Market Adjusted Index Rate

The Market Adjusted Index rate is calculated as the Index Rate adjusted for all allowable market wide modifiers defined in the market rating rules. This development is presented in Exhibit A: Market Adjusted Index Rate Development.

The projected Federal MLR for the products in this filing is estimated in Exhibit M: Federal MLR Estimated Calculation. Please note that this calculation is purely an estimate and not meant to be a true measure for Federal or State MLR rebate purposes. The MLR for Anthem's entire book of Individual business will be compared to the minimum Federal benchmark for purposes of determining regulation-related premium refunds. Also note that the projected Federal MLR presented here does not capture all adjustments, including but not limited to: three-year averaging, credibility, dual option, and deductible. Anthem's projected MLR is expected to meet or exceed the minimum MLR standards at the market level after including all adjustments.

14. Single Risk Pool

The Anthem Index Rate for Individual business in Connecticut is based on total combined claims costs for providing essential health benefits within the single risk pool of non-grandfathered Individual plans in Connecticut. The Index Rate is adjusted on a market-wide basis for the state based on the total expected market-wide payments and charges under the risk adjustment and reinsurance programs and Exchange user fees. The premium rates for all Anthem non-grandfathered plans in the Individual market use the applicable market-wide adjusted index rate, subject only to the permitted plan-level adjustments. This demonstrates that the Single Risk Pool for Anthem Individual business is established according to the requirements in 45 CFR part 156, §156.80(d).

15. Index Rate

• Experience Period Index Rate

The index rate represents the average allowed claims PMPM of essential health benefits for Anthem's Individual Non-Grandfathered Business. The experience period index rate shown in Worksheet 1, Section I (cell G17) of the Unified Rate Review Template is $502.00.


18. Calibration

The required premium in the projection period is calibrated by the average rating calibration factors (Age and Area), which are used to develop the Consumer Adjusted Premium Rates. The average rating factors are shown in Exhibit H: Calibration, Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates.

• Age Factors

Refer to Exhibit J: Age and Tobacco Factors.

The average age rating factor shown in Exhibit H: Calibration is calculated as a member-weighted average of the age rating factors, using the projected age distribution assumptions in our pricing model, with an adjustment for the maximum of 3 child dependents under age 21. Using the same methodology, the approximate average age rounded to the nearest whole number for the associated risk pool is 49.

• Area Factors

• Plan Level Modifiers

Cost Sharing Adjustments: This is a multiplicative factor that adjusts for the projected paid/allowed ratio of each plan, based on the AV metal value with an adjustment for utilization differences due to differences in cost sharing.

Provider Network Adjustments: This is a multiplicative factor that adjusts for differences in projected claims cost due to different network discounts.

Adjustments for Benefits in Addition to EHBs: This multiplicative factor adjusts for additional benefits that are not EHBs.

Adjustments for Administrative Cost: This is an additive adjustment that includes all the Selling Expense, Administration and Retention Items shown in Exhibit G: Non-Benefit Expenses and Profit & Risk, with the exception of the Exchange User Fee since it is already included in the Market Adjusted Index Rate.

Catastrophic Factor: This adjustment assumes a healthier than average population will select the catastrophic plan. The catastrophic adjustment factor is only applied to catastrophic plans, as shown in Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates.

17. Plan Adjusted Index Rate

The Plan Adjusted Index Rate is calculated as the Market Adjusted Index Rate adjusted for all allowable plan level modifiers defined in the market rating rules. This development is presented in Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates.

Individual and Uninsured to Medicaid as a result of expanded Medicaid eligibility

The plan distribution is based on assumed metal tier and network distributions. Some 2015 preliminary enrollment information has been considered in projecting membership distributions.

The Actuarial Value (AV) Pricing Values for each Plan ID are in Worksheet 2, Section I of the Unified Rate Review Template. The AV Pricing Value represents the cumulative effect of adjustments made by the issuer to move from the Market Adjusted Index Rate to the Plan Adjusted Index Rate. Consistent with final Market rules, utilization adjustments are made to account for member behavior variations based upon cost-share variations of the benefit design and not the health status of the member. The average allowable modifiers to the Index Rate can be found in Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates.

22. Membership Projections

Membership projections in Worksheet 2 of the Unified Rate Review Template are developed using a population movement model plus adjustments for sales expectations. This model projects the membership in the projection period by taking into account:

Uninsured to Individual as a result of guaranteed issue, subsidized coverage, and individual mandate

Small Group to Individual as a result of guaranteed issue and Small Group insuring decisions

High Risk Pools to Individual as a result of guaranteed issue

19. Consumer Adjusted Premium Rate

The Consumer Adjusted Premium Rate is calculated as the Plan Adjusted Index Rate calibrated as described in the previous section. This development is presented in Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates. The calibration is shown in Exhibit H: Calibration.

20. Actuarial Value Metal Values

The Actuarial Value (AV) Metal Values included in Worksheet 2 of the Unified Rate Review Template are based on the AV Calculator. To the extent a component of the benefit design was not accommodated by an available input within the AV Calculator, the benefit characteristic was adjusted to be actuarially equivalent to an available input within the AV Calculator for purposes of utilizing the AV Calculator as the basis for the AV Metal Values. Benefits for plans that are not compatible with the parameters of the AV Calculator have been separately identified and documented in the Unique Plan Design Supporting Documentation and Justification that supports the Plan & Benefits Template.

21. Actuarial Value Pricing Values

Current capital and surplus for Anthem Health Plans, Inc. is $311,734,534 as shown on page 5, line 49 of the 2014 Annual Statement.

25. Terminated Products

The list of terminated plans is shown in Exhibit O: Terminated Plans.

26. Plan Type

Plan types in Worksheet 2, Section I of the URRT adequately describe Anthem's plans.

27. Effective Rate Review Information

The RBC Ratio for Anthem Health Plans, Inc. is 551.11% as of 12/31/2014.

24. New Tiered-Network Benefit Plans

The 2016 Individual plan portfolio contains four new plans with tiered in-network benefits. These plans have up to three networks of provider care and different cost share provisions for each network:

The Tier 1 network is a subset of preferred in-network providers; members have the lowest cost share amounts when utilizing this preferred network.

The Tier 2 network is comprised of the remaining in-network providers and has higher cost share amounts compared to the Tier 1 network.

For tiered PPO plans, the Tier 3 network is comprised of the out-of-network providers and has the highest cost share amounts.

Additional cost of care savings are expected from increased utilization of Tier 1 providers. These savings are used to reduce the tiered plan rate compared to a non-tiered plan with similar cost share provisions

The projected morbidity changes shown in Exhibit D: Projection Period Adjustments include expected morbidity changes due to population movement.

Cost share reduction subsidies will be available on silver level plans. Anthem ran projections to estimate enrollment by income level in each of the plans. Projected enrollment by plan and subsidy level can be found in Exhibit P: Membership Projections for Cost-Sharing Reductions.

23. Warning Alerts

There are warning alerts in cells A54 and A56 on Worksheet 2, Section III of the Unified Rate Review Template. This is because Plan Adjusted Index Rates are only entered for single risk pool compliant plans on Worksheet 2, whereas the Worksheet 1 average premium rate reflects the experience of all non-grandfathered (single risk pool compliant and non-ACA) policies. An additional impact is due to differences in the distribution of ages, geography, and benefits that was projected when developing rates versus what actually emerged

30. Actuarial Certification

I, John Bryson, ASA, MAAA, am an actuary for Anthem. I am a member of the American Academy of Actuaries and an Associate of the Society of Actuaries. I meet the Qualification Standards of the American Academy of Actuaries to render the actuarial opinion contained herein. I hereby certify that the following statements are true to the best of my knowledge with regards to this filing:

(1) The projected Index Rate is:

There are no new benefit mandates or requirements due to changes in either state or federal law included in the 2016 plan benefits.

Exhibit R: Claim Lag Triangle shows the claim lag triangle for the experience data.

The Annual Certification for substituting non-dollar limits on an essential health benefit can be found in Exhibit T: Annual Certification

Appendix A in conjunction with Exhibit I: Non-Grandfathered Rate Changes show a summary of the requested rate changes.

29. Reliance

In support of this rate development, various data and analyses were provided by other members of Anthem's internal actuarial staff, including data and analysis related to cost of care, valuation, and pricing. I have reviewed the data and analyses for reasonableness and consistency. I have relied on Wakely Consulting to provide the actuarial certification for the Unique Plan Design Supporting Documentation for the On Exchange Standard plans required by the Connecticut state exchange. I have also relied on Michele Archer, FSA, MAAA to provide the actuarial certification for the Unique Plan Design Supporting Documentation and Justification for the other plans included in this filing.

28. State Actuarial Memorandum Requirements

Supplemental material to satisfy the filing requirements from Bulletin HC-81-15 and Bulletin HC-90-15.

The proposed retention charge in the rate development is 20.2%. This is comprised of both fixed and variable expenses and includes selling expense, administrative expense, federal fees, federal income tax, ACA fees, exchange fees and risk and net profit margin. The December 31, 2014 Annual Statement for Anthem Health Plans, Inc. has a retention amount of 21.6%. This amount is calculated from the Analysis of Operations by Lines of Business exhibit on page 7: 1 – [line 17, column 2 $1,013,710,674 / line 7, column 2 $1,293,424,687] = 21.6%.

Exhibit Q: Trend Exhibit details Anthem's unit cost trend, utilization trend, technology trend, and other trend components.

Benefit buy-down analysis and impact on trend: No explicit buy-down impact was used in the rate development.

Date

John Bryson, ASA, MAAAActuary & Director I

April 30, 2015

Not excessive, deficient, or unfairly discriminatory.

(2) 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.

(3) The percent of total premium that represents essential health benefits included in Worksheet 2, Sections III and IV of the Part I Unified Rate Review Template is calculated in accordance with Actuarial Standards of Practice.

(4) The geographic rating factors reflect only differences in the costs of delivery (which can include unit cost and provider practice pattern differences) and do not include differences for population morbidity by geographic area.

(5) The most recent 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.

The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the rates. Rather it represents information required by Federal regulation to be provided in support of the review of rate changes, for certification of Qualified Health Plans for Federally-Facilitated Exchanges, and for certification that the Index Rate is developed in accordance with Federal regulation, used consistently, and only adjusted by the allowable modifiers. However, this Actuarial Memorandum does accurately describe the process used by the issuer to develop the rates.

In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.80(d)(1))

Developed in compliance with the applicable Actuarial Standards of Practice

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

Experience Rate1) Starting Paid Claims PMPM 448.59$ Exhibit B2) x Seasonality 1.0068 3) x Wakely Adjustment {1} 0.9294 4) Mature Claims PMPM 419.75$ = (1) x (2) x (3)

5) x Normalization Factor 0.9536 Exhibit C6) = Normalized Claims 400.27$ = (4) x (5)

7) x Benefit Changes 1.0007 Exhibit D8) x Morbidity Changes 0.9336 Exhibit D9) x Trend Factor 1.1545 Exhibit D

10) x Other Cost of Care Impacts 0.9996 Exhibit D11) Projected Paid Claim Cost 431.56$ = (6) x (7) x (8) x (9) x (10)

12) Credibility Weight 100%13) Blended Paid Claims $431.5614) - Non-EHBs Embedded in Line Item (1) Above $0.9815) = Projected Paid Claims, Excluding ALL Non-EHBs $430.5816) + Rx Rebates -$10.56 Exhibit E17) + Additional EHBs {2} $4.01 Exhibit E18) = Projected Paid Claims Reflecting only EHBs $424.0319) ÷ Paid to Allowed Ratio 0.7991020) = Projected Allowed Claims Reflecting only EHBs $530.63 = Index Rate

21) Reinsurance Contribution $2.25 Exhibit F22) Expected Reinsurance Payments -$34.85 Exhibit F23) Risk Adjustment Fee $0.15 Exhibit F24) Risk Adjustment Net Transfer -$0.43 Exhibit F25) Exchange Fee $6.6326) Market Adjusted Index Rate {3} $497.78 = [(18)+(21)+(22)+(23)+(24)+(25)] ÷ (19)

Notes:{1} Adjustment based on Wakely survey to bring starting experience in-line with the market{2} Pediatric Dental and Pediatric Vision{3} The Market Adjusted Index Rate is the same for all plans in the single risk pool

Exhibit A - Market Adjusted Index Rate Development



CSR Total Member TotalMedical Drug Medical Drug Medical Drug Capitation Receivable Benefit Expense Months PMPM194,410,535$ 41,176,361$ 13,988,977$ 20,823$ 208,399,512$ 41,197,184$ -$ (13,115,992)$ 236,480,704$ 527,166 448.59$

CSR Total Member TotalMedical Drug Medical Drug Medical Drug Capitation Receivable Benefit Expense Months PMPM234,966,958$ 51,258,059$ 16,520,160$ 24,377$ 251,487,118$ 51,282,436$ -$ N/A 302,769,555$ 527,166 574.33$

Notes:

The claims shown above in the Experience Rate Claims Experience do not account for Non-ACA Plans or Rx Rebates; whereas, the claims shown in Worksheet 1, Section 1 of the Unified Rate Review Template do include those pieces.Drug Claims are processed by an external vendor.

Incurred and Paid Claims: IBNR: Fully Incurred Claims:

PAID CLAIMS:Incurred and Paid Claims: IBNR: Fully Incurred Claims:

ALLOWED CLAIMS:

Exhibit B - Claims Experience for Rate Developments


Experience Rate Claims ExperienceIncurred January 1, 2014 through December 31, 2014

Paid through March 31, 2015

Experience Period Population

Future Population

Normalization Factor

Age/Gender 1.0432 1.0314 0.9887Area 0.9591 0.9598 1.0007Network 0.9511 0.9590 1.0083Benefit Plan 0.6895 0.6591 0.9559Total 0.9536

Exhibit C - Normalization Factors



Average Claim Factors

Experience RateBenefit changes

Rx Adjustments {1} 1.0007Total Benefit Changes 1.0007

Morbidity changesTotal Morbidity Changes 0.9336

Cost of care impactsAnnual Medical/Rx Trend Rate 7.57%# Months of Projection 23.63Trend Factor 1.1545

Medical Management 1.0002Induced Demand for CSR 0.9970Grace Period 1.0024Total other Impacts 0.9996

Notes:

Exhibit D - Projection Period Adjustments



Impact of Changes Between Experience Period and Projection Period:

{1} Includes Rx formulary and impacts for moving drugs into different tiers

PMPMRx Rebates ($10.56)Pediatric Dental $3.53Pediatric Vision $0.48Total ($6.55)

Notes:

Exhibit E - Other Claim Adjustments



Adjustments to projection period claims to reflect covered benefits not included in experience period data:

Adjustments above reflect ONLY additional costs beyond those already captured in line Item 15 of Exhibit A.

Risk Adjustment:PMPM User Fee Net Transfer Federal Program $0.15 ($0.43)

Reinsurance:

PMPM Contributions Made Expected Receipts

Federal Program $2.25 ($34.85)

Source:

Grand Total of All Risk Mitigation Programs ($32.88)

HHS estimates a national per capita contribution rate of $2.25 per month ($27 per year) in benefit year 2016 (per Payment Parameter Rule).

Exhibit F - Risk Adjustment and Reinsurance - Contributions and Payments



Expenses Applied As a PMPM Cost

Expenses Applied as a % of Premium

Expressed as a PMPM {1}

Administrative ExpensesAdministrative Costs $30.54Quality Improvement Expense $3.61Selling Expense 1.20%Specialty Expenses $0.62Misc Admin (PMPM) {2} $1.47

Total Administrative Expenses $36.24 1.20% $42.14Taxes and Fees

PCORI Fee $0.18ACA Insurer Fee 2.90%Exchange Fee 1.35%Premium Tax 1.75%MLR-Deductible Federal/State Income Taxes {3} 1.75%Misc Taxes & Fees (% prem) {4} 0.53%

Total Taxes and Fees $0.18 $0.08 $40.83Profit and Risk {5} 3.25% $15.96Total Non-Benefit Expenses, Profit, and Risk $36.42 12.73% $98.92

Notes:

{3} Includes only those income taxes which are deductible from the MLR denominator; in particular, Federal income taxes on investment income are excluded.{4} Includes charges for DOI Fees and Assessments{5} Profit shown here is post-tax profit, net of those federal and state income taxes which are deductible from the MLR denominator.

Exhibit G - Non-Benefit Expenses and Profit & Risk



{1} The sum of the rounded percentages shown may not equal the total at the bottom of the table due to rounding.{2} Includes charge for State of Connecticut Vaccine Immunization Program.

Calibration FactorsAge 1.6725Area 0.9598Total Calibration Factor 1.6052

Notes:

When computing family premiums, no more than the three oldest covered children under the age of 21 are taken into account, whereas the premiums associated with each child age 21+ are included. As such, the average rating factor was adjusted to reflect the portion of the population under age 21 for which the calibration can be made.

Exhibit H - Calibration



Average 2016 rating factors for 2016 population:

See Calibration Factor on Exhibit N.

1







Notes:





Age Factors Tobacco FactorsAge 2016 20160-17 0.635 1.00018 0.635 1.00019 0.635 1.00020 0.635 1.00021 1.000 1.00022 1.000 1.00023 1.000 1.00024 1.000 1.00025 1.004 1.00026 1.024 1.00027 1.048 1.00028 1.087 1.00029 1.119 1.00030 1.135 1.00031 1.159 1.00032 1.183 1.00033 1.198 1.00034 1.214 1.00035 1.222 1.00036 1.230 1.00037 1.238 1.00038 1.246 1.00039 1.262 1.00040 1.278 1.00041 1.302 1.00042 1.325 1.00043 1.357 1.00044 1.397 1.00045 1.444 1.00046 1.500 1.00047 1.563 1.00048 1.635 1.00049 1.706 1.00050 1.786 1.00051 1.865 1.00052 1.952 1.00053 2.040 1.00054 2.135 1.00055 2.230 1.00056 2.333 1.00057 2.437 1.00058 2.548 1.00059 2.603 1.00060 2.714 1.00061 2.810 1.00062 2.873 1.00063 2.952 1.000

64+ 3.000 1.000

Notes:

Exhibit J - Age and Tobacco Factors



The weighted averages of these factors for the entire risk pool included in this rate filing is detailed in Exhibit H.

Rating Area Description

2016 Area Rating Factor

2015 Area Rating Factor Change

Fairfield 1.1000 1.1000 0.0%Hartford 0.8700 0.8700 0.0%Litchfield 0.8700 0.8700 0.0%

Middlesex 0.9500 0.9500 0.0%New Haven 0.9500 0.9500 0.0%

New London 0.8700 0.8700 0.0%Tolland 0.8700 0.8700 0.0%

Windham 0.8700 0.8700 0.0%

Notes:The weighted average of these factors for the entire risk pool included in this rate filing is detailed in Exhibit H.

Exhibit K - Area Factors



Name: John DoeEffective Date: 1/1/2016On/Off Exchange: OffMetal Level: BronzePlan ID: 86545CT1310019Rating Area: 01

Family Members Covered:Age

Subscriber 47Spouse 42

Child (age 21+) 25Child #1 20Child #2 16

Calculation of Monthly Premium:Consumer Adjusted Premium Rate $ 243.97 Exhibit Nx Area Factor 1.1000 Exhibit KRate Adjusted for Area = $ 268.37

Age Factors Exhibit J:Age Factor

Subscriber 1.563Spouse 1.325

Child (age 21+) 1.004Child #1 0.635Child #2 0.635

Final Monthly Premium PMPM:PMPM

Subscriber 419.46$ Spouse 355.59$

Child (age 21+) 269.44$ Child #1 170.41$ Child #2 170.41$ TOTAL 1,385.31$

Notes:

Minor rate variances may occur due to differences in rounding methodology.

As per the Market Reform Rule, when computing family premiums no more than the three oldest covered children under the age of 21 are taken into account whereas the premiums associated with each child age 21+ are included.

Exhibit L - Sample Rate Calculation



Numerator: Incurred Claims 425.01$ Exhibit A (Line 13) + Exhibit E (Total)+ Quality Improvement Expense 3.61$ Exhibit G+ Risk Corridor Contributions -$ + Risk Adjustment Net Transfer (0.43)$ Exhibit F+ Reinsurance Receipts (34.85)$ Exhibit F+ Risk Corridor Receipts -$ + Reduction to Rx Incurred Claims (ACA MLR) (6.87)$ {1}= Estimated Federal MLR Numerator 386.47$

Denominator: Premiums 491.05$ Incurred Claims + Exhibit F (Total) + Exhibit G (Total)- Federal and State Taxes 8.59$ Premiums x Exhibit G (Income Taxes)- Premium Taxes 8.59$ Premiums x Exhibit G (Premium Tax)- Risk Adjustment User Fee 0.15$ Exhibit F- Reinsurance Contributions 2.25$ Exhibit F- Misc Admin (PMPM) 1.47$ Exhibit G- Misc Taxes & Fees (% of Premium) 2.59$ Exhibit G- Licensing and Regulatory Fees $21.05 Premiums x Exhibit G (Fees)= Estimated Federal MLR Denominator 446.36$

Estimated Federal MLR 86.58%

Notes:

The above calculation is purely an estimate and not meant to be compared to the minimum MLR benchmark for federal/state MLR rebate purposes:

* The above calculation represents only the products in this filing. Federal MLR will be calculated at the legal entity and market level.

* Not all numerator/denominator components are captured above (for example, fraud and prevention program costs, payroll taxes, assessments for state high risk pools etc.).

* Other adjustments may also be applied within the federal MLR calculation such as 3-year averaging, new business, credibility, deductible and dual option. These are ignored in the above calculation.

* Licensing and Regulatory Fees include ACA-related fees as allowed under the MLR Final Rule.

Exhibit M - Federal MLR Estimated Calculation



{1} This is the percentage of 2016 pharmacy claims that are attributable to PBM Administrative Expenses (i.e. the "retail spread" or "pharmacy claims margin"). It is calculated by applying the 3rd party margin percentage to the 2016 projected Pharmacy claims including projected rebates.

HIOS Plan Name HIOS Plan ID

Market Adjusted Index Rate (Exhibit

A)Cost Sharing Adjustment

Provider Network

Adjustment

Adjustment for Benefits in Addition

to the EHBS

Catastrophic Plan Adjustment

{1} Administrative Costs

Plan Adjusted Index Rate

{2}

Calibration Factor

{3}

Consumer Adjusted Premium Rate

{4}Catastrophic HMO Pathway X Enhanced 86545CT1230005 $497.78 0.5249 0.9645 1.0043 0.8267 $48.72 $257.96 1.6052 $160.70Bronze HMO Pathway X Enhanced for HSA 86545CT1230001 $497.78 0.6021 0.9645 1.0031 1.0000 $67.32 $357.30 1.6052 $222.59Bronze HMO Pathway X Enhanced 86545CT1230002 $497.78 0.6491 0.9645 1.0029 1.0000 $72.50 $385.05 1.6052 $239.88Gold HMO Pathway X Enhanced 86545CT1230004 $497.78 0.9558 0.9645 1.0020 1.0000 $106.33 $566.12 1.6052 $352.68Anthem HMO Catastrophic BlueCare 6850/0% 86545CT1310033 $497.78 0.5248 1.0451 1.0043 0.8267 $52.73 $279.42 1.6052 $174.07Anthem Bronze HMO BlueCare 6000/12000/0% for HSA 86545CT1310019 $497.78 0.6092 1.0451 1.0031 1.0000 $73.73 $391.62 1.6052 $243.97Anthem Bronze HMO BlueCare 6000/0% 86545CT1310024 $497.78 0.6333 1.0451 1.0030 1.0000 $76.61 $407.07 1.6052 $253.59Anthem Bronze HMO BlueCare 6550/13100/0% for HSA 86545CT1310039 $497.78 0.5248 1.0451 1.0036 1.0000 $63.64 $337.62 1.6052 $210.33Anthem Silver HMO BlueCare 3500/7000/0% for HSA 86545CT1310030 $497.78 0.7429 1.0451 1.0025 1.0000 $89.70 $477.17 1.6052 $297.27Anthem Silver HMO BlueCare 3500/0% 86545CT1310031 $497.78 0.7729 1.0451 1.0024 1.0000 $93.28 $496.34 1.6052 $309.21Anthem Silver HMO BlueCare Tiered 3000/3850/0% 86545CT1310040 $497.78 0.6907 1.0451 1.0027 1.0000 $83.47 $443.78 1.6052 $276.46Anthem Gold HMO BlueCare 1500/0% 86545CT1310032 $497.78 0.9557 1.0451 1.0020 1.0000 $115.13 $613.28 1.6052 $382.06Anthem Gold HMO Pathway X Enhanced 1850/0% 86545CT1310035 $497.78 0.9004 0.9645 1.0021 1.0000 $100.20 $533.38 1.6052 $332.28Anthem Gold HMO BlueCare Tiered 2000/3500/0% 86545CT1310043 $497.78 0.8562 1.0451 1.0022 1.0000 $103.23 $549.63 1.6052 $342.41Bronze PPO Standard Pathway X 86545CT1330002 $497.78 0.6428 0.9741 1.0029 1.0000 $72.49 $385.08 1.6052 $239.90Bronze PPO Standard Pathway X for HSA 86545CT1330009 $497.78 0.5834 0.9741 1.0032 1.0000 $65.87 $349.65 1.6052 $217.82Silver PPO Standard Pathway X 86545CT1330001 $497.78 0.8504 0.9741 1.0022 1.0000 $95.63 $508.90 1.6052 $317.03Silver PPO Pathway X 86545CT1330004 $497.78 0.8625 0.9741 1.0022 1.0000 $96.97 $516.12 1.6052 $321.53Gold PPO Standard Pathway X 86545CT1330003 $497.78 1.0257 0.9741 1.0018 1.0000 $115.16 $613.44 1.6052 $382.16Anthem Bronze PPO Century Preferred 5700/11400/20% for HSA 86545CT1340005 $497.78 0.5452 1.0556 1.0035 1.0000 $66.73 $354.21 1.6052 $220.66Anthem Bronze PPO Century Preferred 6850/0% 86545CT1340010 $497.78 0.5165 1.0556 1.0036 1.0000 $63.26 $335.65 1.6052 $209.10Anthem Silver PPO Century Preferred 2750/20% 86545CT1340006 $497.78 0.7512 1.0556 1.0025 1.0000 $91.58 $487.28 1.6052 $303.56Anthem Silver PPO Century Preferred 2500/20% 86545CT1340007 $497.78 0.7697 1.0556 1.0024 1.0000 $93.82 $499.26 1.6052 $311.03Anthem Silver PPO Century Preferred 3000/6000/20% for HSA 86545CT1340011 $497.78 0.6942 1.0556 1.0027 1.0000 $84.70 $450.46 1.6052 $280.63Anthem Silver PPO Century Preferred 3500/7000/10% 86545CT1340014 $497.78 0.6764 1.0556 1.0028 1.0000 $82.55 $438.94 1.6052 $273.45Anthem Silver PPO Century Preferred Tiered 2850/4000/0% 86545CT1340015 $497.78 0.6888 1.0556 1.0027 1.0000 $84.06 $446.97 1.6052 $278.45Anthem Gold PPO Century Preferred 1500/3000/20% for HSA 86545CT1340012 $497.78 0.8953 1.0556 1.0021 1.0000 $108.98 $580.39 1.6052 $361.57Anthem Gold PPO Century Preferred 1750/0% 86545CT1340013 $497.78 0.9543 1.0556 1.0020 1.0000 $116.10 $618.50 1.6052 $385.31Anthem Gold PPO Century Preferred Tiered 1750/3250/0% 86545CT1340016 $497.78 0.8813 1.0556 1.0021 1.0000 $107.29 $571.37 1.6052 $355.95Gold HMO Pathway X Enhanced, a Multi-State Plan 86545CT1470002 $497.78 0.9023 0.9645 1.0000 1.0000 $100.20 $533.38 1.6052 $332.28Silver PPO Pathway X, a Multi-State Plan 86545CT1480002 $497.78 0.8634 0.9741 1.0000 1.0000 $96.86 $515.51 1.6052 $321.15

Notes:

{2} The Plan Adjusted Index Rate is calculated by multiplying the Market Adjusted Index Rate by the AV and cost sharing, provider network, benefits in addition to the EHBs, and catastrophic plan adjustments and then adding the administrative costs. The Plan Adjusted Index Rate can also be described as a Plan Level Required Premium.{3} See Exhibit H - Calibration.{4} The Consumer Adjusted Premium Rate is calculated by dividing the Plan Adjusted Index Rate by 'Calibration Factor'. The Consumer Adjusted Premium Rate can also be described as a Plan Level Base Rate.

Exhibit N - Plan Adjusted Index Rate and Consumer Adjusted Premium Rates



{1} This adjustment assumes a healthier than average population will select the catastrophic plan.

Following are the plans that will be terminated prior to the effective date:

Plan ID Plan Name HIOS Product ID HIOS Product Name86545CT1310018 Anthem HMO BlueCare 0% for HSA 86545CT131 HMO Off-Exchange86545CT1310020 Anthem HMO BlueCare 5500/0% 86545CT131 HMO Off-Exchange86545CT1340008 Anthem HMO BlueCare 3500/0% 86545CT134 PPO Off-Exchange

Post ACA Terminated Plans

Exhibit O - Terminated Plans


Effective January 1, 2016

This includes plans that have experience included in the URRT during the experience period and any plans that were not in effect during the experience period but were made available thereafter.

Silver PlanHIOS Standard Component Plan ID 100-150% 150%-200% 200%-250% Standard

86545CT1310030 0 0 0 3,20086545CT1310031 0 0 0 70086545CT1310040 0 0 0 40086545CT1330001 3,522 3,243 1,895 5,14086545CT1330004 1,148 1,058 618 1,67686545CT1340006 0 0 0 70086545CT1340007 0 0 0 40086545CT1340011 0 0 0 1,00086545CT1340014 0 0 0 40086545CT1340015 0 0 0 40086545CT1480002 179 165 96 260

Exhibit P - Membership Projections for Cost-Sharing Reductions



Projected Membership by Subsidy Level:

Rating Trend

Leveraging

Historical Cost and Utilization Paid Data

Inpatient Outpatient Professional Rx Drug TotalUnit Cost Data

CY 2011 $3,369.11 $655.43 $154.82 $80.64CY 2012 $3,559.74 $731.71 $154.78 $86.48CY 2013 $3,800.97 $807.64 $157.70 $92.84CY 2014 $3,887.58 $841.22 $163.02 $106.20CY 2015 $4,069.07 $912.36 $165.21 $124.60CY 2016 $4,255.61 $985.15 $169.40 $142.64

Utilization Data (per thousand members)

CY 2011 23.5 136.5 875.9 1,063.3 2,099.2CY 2012 23.5 136.8 881.6 1,063.9 2,105.7CY 2013 22.0 136.7 874.2 1,090.6 2,123.5CY 2014 22.6 137.4 897.5 1,063.9 2,121.4CY 2015 22.5 137.4 901.1 1,055.4 2,116.4CY 2016 22.5 137.4 902.0 1,047.0 2,108.9

Paid PMPM

CY 2011 $79.02 $89.49 $135.61 $85.75 $389.87CY 2012 $83.79 $100.07 $136.45 $92.01 $412.32CY 2013 $83.80 $110.38 $137.86 $101.25 $433.30CY 2014 $87.68 $115.55 $146.32 $112.99 $462.54CY 2015 $91.63 $125.37 $148.87 $131.50 $497.37CY 2016 $95.75 $135.40 $152.80 $149.34 $533.29

Paid Trend

2012/2011 6.0% 11.8% 0.6% 7.3% 5.8%2013/2012 0.0% 10.3% 1.0% 10.0% 5.1%2014/2013 4.6% 4.7% 6.1% 11.6% 6.7%2015/2014 4.5% 8.5% 1.7% 16.4% 7.5%2016/2015 4.5% 8.0% 2.6% 13.6% 7.2%

Notes:

The use of Paid Claims removes the need to adjust for Leveraging.

Other Trend ComponenMedical technology trend is included in observed experience and is not an independent assumption.

This exhibit shows Small Group trend data because Small Group claims data was used as the basis for the Individual pricing trend.

Observed Paid TrendsObserved trends have been normalized to remove the impact of aging and morbidity, shifts in gender, medical initiatives and mandates, and impact of medical benefit changes.

Benefit Buy Downs

Cost and utilization data in the experience periods includes the impact of benefit buy-downs. The trend process is normalized for benefit buy-down to develop a projected trend for 2015 and 2016.

Provider ContractingProvider contracting is included in the Unit Cost Data.

Exhibit Q - Trend Exhibit



Based on the considerations below, Anthem proposes a 7.6% rating trend. The rating trend is developed from the expected paid trend.

Lag

Incurred 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

201401 639,973 1,054,547 1,165,202 1,686,620 961,121 1,317,924 579,168 553,201 719,446 366,056 364,842 41,395 -2,165 -39,000

201402 1,002,577 2,013,129 1,831,654 1,498,392 1,726,047 1,292,607 829,628 499,855 649,502 356,286 160,135 99,566 20,644 15,119

201403 3,165,745 3,836,259 2,666,371 2,356,323 992,528 324,321 469,642 846,551 291,529 484,070 182,418 35,239 95,954

201404 3,614,592 7,061,201 3,049,824 1,085,529 772,397 379,866 1,065,789 463,273 310,660 93,922 58,443 -23,380

201405 6,221,514 8,675,490 1,955,028 659,017 535,139 804,307 724,813 271,846 137,540 118,069 -289,703

201406 7,856,397 8,215,780 2,012,289 1,135,369 782,887 735,299 347,613 233,584 102,908 -82,335

201407 7,169,970 9,865,626 2,416,227 1,231,513 575,513 440,544 130,251 -11,362 -93,026

201408 8,172,181 9,958,250 2,673,857 517,333 346,736 143,062 127,887 -48,774

201409 7,768,556 12,086,499 1,164,459 450,672 444,061 147,445 -144,475

201410 9,307,182 11,506,790 3,236,533 550,505 120,119 142,455

201411 8,046,365 12,772,673 1,417,804 513,344 341,156

201412 12,379,515 10,751,957 1,333,674 685,965

Notes:{1} As noted in Section 28. State Actuarial Memorandum Requirements, this exhibit displays the claim lag triangle for Individual ACA experience, which was the basis of the Individual rate development.

Exhibit R - Claim Lag TriangleAnthem Health Plans, Inc.

Individual


CT Individual CT Individual Non-ACA CT Individual ACA

Member Months Premium PMPM

Incurred Benefit Expense PMPM

Paid Benefit Expense PMPM

Incurred Loss Ratio

Paid Loss Ratio Member Months Premium

PMPM



Incurred Loss Ratio

Paid Loss Ratio

Member Months

Premium PMPM



Incurred Loss Ratio

Paid Loss Ratio

CY 2010 669,297 $306.18 $231.05 $235.16 75.5% 76.8% 669,297 $306.18 $231.05 $235.16 75.5% 76.8% - $0.00 $0.00 $0.00 0.0% 0.0%CY 2011 638,974 $311.05 $263.05 $255.73 84.6% 82.2% 638,974 $311.05 $263.05 $255.73 84.6% 82.2% - $0.00 $0.00 $0.00 0.0% 0.0%CY 2012 611,781 $313.13 $285.94 $287.60 91.3% 91.8% 611,781 $313.13 $285.94 $287.60 91.3% 91.8% - $0.00 $0.00 $0.00 0.0% 0.0%

201301 49,030 $344.66 $233.38 $279.25 67.7% 81.0% 49,030 $344.66 $233.38 $279.25 67.7% 81.0% - $0.00 $0.00 $0.00 0.0% 0.0%201302 48,374 $343.70 $252.99 $244.21 73.6% 71.1% 48,374 $343.70 $252.99 $244.21 73.6% 71.1% - $0.00 $0.00 $0.00 0.0% 0.0%201303 47,906 $343.12 $255.70 $261.66 74.5% 76.3% 47,906 $343.12 $255.70 $261.66 74.5% 76.3% - $0.00 $0.00 $0.00 0.0% 0.0%201304 47,782 $341.39 $278.89 $300.75 81.7% 88.1% 47,782 $341.39 $278.89 $300.75 81.7% 88.1% - $0.00 $0.00 $0.00 0.0% 0.0%201305 47,462 $340.75 $300.68 $299.32 88.2% 87.8% 47,462 $340.75 $300.68 $299.32 88.2% 87.8% - $0.00 $0.00 $0.00 0.0% 0.0%201306 47,174 $340.64 $290.35 $293.04 85.2% 86.0% 47,174 $340.64 $290.35 $293.04 85.2% 86.0% - $0.00 $0.00 $0.00 0.0% 0.0%201307 46,863 $340.22 $315.00 $314.27 92.6% 92.4% 46,863 $340.22 $315.00 $314.27 92.6% 92.4% - $0.00 $0.00 $0.00 0.0% 0.0%201308 46,447 $339.86 $315.46 $315.27 92.8% 92.8% 46,447 $339.86 $315.46 $315.27 92.8% 92.8% - $0.00 $0.00 $0.00 0.0% 0.0%201309 46,025 $338.97 $305.49 $318.51 90.1% 94.0% 46,025 $338.97 $305.49 $318.51 90.1% 94.0% - $0.00 $0.00 $0.00 0.0% 0.0%201310 45,264 $339.50 $353.07 $328.52 104.0% 96.8% 45,264 $339.50 $353.07 $328.52 104.0% 96.8% - $0.00 $0.00 $0.00 0.0% 0.0%201311 44,289 $339.85 $349.27 $356.93 102.8% 105.0% 44,289 $339.85 $349.27 $356.93 102.8% 105.0% - $0.00 $0.00 $0.00 0.0% 0.0%201312 43,125 $323.73 $404.02 $397.00 124.8% 122.6% 43,125 $323.73 $404.02 $397.00 124.8% 122.6% - $0.00 $0.00 $0.00 0.0% 0.0%CY 2013 559,741 $339.85 $302.95 $307.77 89.1% 90.6% 559,741 $339.85 $302.95 $307.77 89.1% 90.6% - $0.00 $0.00 $0.00 0.0% 0.0%

201401 47,016 $403.27 $215.94 $194.05 53.5% 48.1% 15,509 $257.76 $136.44 $588.29 52.9% 228.2% 31,507 $474.89 $255.07 $0.00 53.7% 0.0%201402 49,399 $412.03 $227.83 $95.17 55.3% 23.1% 14,595 $262.63 $106.32 $209.59 40.5% 79.8% 34,804 $474.68 $278.79 $47.19 58.7% 9.9%201403 51,760 $415.89 $301.01 $173.42 72.4% 41.7% 14,107 $254.54 $192.08 $194.42 75.5% 76.4% 37,653 $476.34 $341.82 $165.55 71.8% 34.8%201404 55,574 $417.22 $302.77 $227.71 72.6% 54.6% 13,612 $260.41 $150.26 $162.14 57.7% 62.3% 41,962 $468.09 $352.25 $248.98 75.3% 53.2%201405 61,315 $415.83 $315.64 $352.88 75.9% 84.9% 13,262 $260.19 $176.77 $188.74 67.9% 72.5% 48,053 $458.78 $353.96 $398.19 77.2% 86.8%201406 61,130 $441.61 $331.01 $439.27 75.0% 99.5% 13,067 $289.44 $157.02 $170.44 54.2% 58.9% 48,063 $482.97 $378.31 $512.36 78.3% 106.1%201407 60,732 $414.43 $338.25 $397.39 81.6% 95.9% 12,822 $264.99 $194.55 $164.19 73.4% 62.0% 47,910 $454.42 $376.71 $459.81 82.9% 101.2%201408 60,487 $414.02 $359.77 $419.86 86.9% 101.4% 12,600 $264.85 $174.89 $173.14 66.0% 65.4% 47,887 $453.27 $408.41 $484.78 90.1% 107.0%201409 60,253 $589.49 $212.09 $432.90 36.0% 73.4% 12,310 $265.47 $176.48 $192.32 66.5% 72.4% 47,943 $672.68 $221.24 $494.67 32.9% 73.5%201410 59,877 $416.91 $324.33 $547.21 77.8% 131.3% 11,993 $267.05 $231.45 $216.60 86.7% 81.1% 47,884 $454.45 $347.59 $630.01 76.5% 138.6%201411 59,263 $417.84 $345.32 $461.22 82.6% 110.4% 11,830 $261.96 $194.79 $218.55 74.4% 83.4% 47,433 $456.72 $382.87 $521.74 83.8% 114.2%201412 57,423 $538.18 $375.78 $595.24 69.8% 110.6% 11,468 $257.40 $278.27 $228.00 108.1% 88.6% 45,955 $608.25 $400.11 $686.88 65.8% 112.9%CY 2014 684,229 $442.66 $306.84 $370.99 69.3% 83.8% 157,175 $263.75 $177.90 $231.05 67.4% 87.6% 527,054 $496.01 $345.29 $285.74 69.6% 57.6%

Notes:[1] Premium includes expected risk adjustment and federal reinsurance program adjustments.{2} Incurred and Paid benefit expenses include capitation, drug rebates, medical management fees, claims expense reclasses, CSR subsidies, Reinsurance recoveries, and other non-core claim accounts.

{3} As noted in Section 5. Experience Period Premium and Claims, this exhibit details historical experience for the policy forms included in this filing.

Exhibit S - Historical Experience


John Bryson, A.S.A., M.A.A.A.Director and Actuary 128-Apr-15

Exhibit T - Annual Certification

Anthem Health Plans – ConnecticutActuarial Certification

I, John Bryson, am an Actuarial Director for Anthem Health Plans. I am a member of the American Academy of Actuaries and an Associate of the Society of Actuaries. I meet the Qualification Standards of the American Academy of Actuaries to render the actuarial opinion herein. I certify that the following statements are true to the best of my knowledge:

• The Mandated Benefits Review Project 2009 stated that many high quality wigs are in excess of $350. Using that analysis and trending the expected cost to 2016, the substitution of 1 wig per year to replace the annual dollar maximum of $350 indicates that the 1 wig per year is at least equal to or greater than the $350 dollar annual limit.


Exchange Metal LevelFebruary 2015

Covered MembersFebruary 2015

Covered Policyholders2015 HIOS Plan ID

MappingCatastrophic HMO Pathway X Enhanced 86545CT1230005 On Catastrophic 605 588 86545CT1230005Bronze PPO Standard Pathway X for HSA 86545CT1330009 On Bronze 1,458 896 86545CT1330009Bronze HMO Pathway X Enhanced for HSA 86545CT1230001 On Bronze 3,189 2,223 86545CT1230001Bronze HMO Pathway X Enhanced 86545CT1230002 On Bronze 1,069 737 86545CT1230002Bronze PPO Standard Pathway X 86545CT1330002 On Bronze 1,707 1,121 86545CT1330002Silver PPO Standard Pathway X 86545CT1330001 On Silver 14,150 10,203 86545CT1330001Silver PPO Pathway X 86545CT1330004 On Silver 4,157 3,059 86545CT1330004Gold HMO Pathway X Enhanced 86545CT1230004 On Gold 1,492 975 86545CT1230004Silver PPO Pathway X, a Multi-State Plan 86545CT1480002 On Silver 773 547 86545CT1480002Gold HMO Pathway X Enhanced, a Multi-State Plan 86545CT1470002 On Gold 366 222 86545CT1470002Gold PPO Standard Pathway X 86545CT1330003 On Gold 5,679 3,370 86545CT1330003Anthem HMO Catastrophic BlueCare 6850/0% 86545CT1310033 Off Catastrophic 329 313 86545CT1310033Anthem Bronze HMO BlueCare 6000/12000/0% for HSA 86545CT1310019 Off Bronze 2,396 1,350 86545CT1310019Anthem Bronze HMO BlueCare 6000/0% 86545CT1310024 Off Bronze 1,244 788 86545CT1310024Anthem Bronze PPO Century Preferred 5700/11400/20% for HSA 86545CT1340005 Off Bronze 3,764 1,957 86545CT1340005Anthem Silver PPO Century Preferred 2750/20% 86545CT1340006 Off Silver 750 401 86545CT1340006Anthem Silver PPO Century Preferred 2500/20% 86545CT1340007 Off Silver 469 240 86545CT1340007Anthem Silver HMO BlueCare 3500/7000/0% for HSA 86545CT1310030 Off Silver 2,888 1,624 86545CT1310030Anthem Silver HMO BlueCare 3500/0% 86545CT1310031 Off Silver 1,968 1,217 86545CT1310031Anthem Gold HMO BlueCare 1500/0% 86545CT1310032 Off Gold 4,442 2,722 86545CT1310032Anthem Gold HMO Pathway X Enhanced 1850/0% 86545CT1310035 Off Gold - - 86545CT1340009

NOTES:

• Information on current and proposed premium PMPM minimums and maximums can be found in the Rate Review Detail section of the CT Individual filing on SERFF.

• The components of the requested rate increase can be found in Exhibit A: Index Rate Development.

{1} Other factors that impact premium rates include age bands and geographic area.

Appendix AAnthem Health Plans - ConnecticutIndividual Plans Effective 1/1/2016

Summary of Requested Rate Changes

• The requested rate change for each product can be found in Exhibit I: - Non-Grandfathered Rate Changes.

• The number of covered individuals and policyholders for each product are shown in the table below.

Anthem Health Plans – Connecticut Actuarial Certification

I, John Bryson, ASA, MAAA am an Actuary for Anthem Health Plans. I am a member of the American Academy of Actuaries and an Associate of the Society of Actuaries. I meet the Qualification Standards of the American Academy of Actuaries to render the actuarial opinion herein. I certify that to the best of my knowledge and judgment that the enclosed rate filing is in compliance with the applicable laws, regulations and bulletins of the State of Connecticut and is in accordance with generally accepted actuarial principles. In my opinion, these rates are not excessive, inadequate, or unfairly discriminatory. My determination was based on information provided by other employees of Anthem Health Plans, and my own analysis.

John Bryson, ASA, MAAA

Director and Actuary 1 April 30, 2015

ACTUARIAL MEMORANDUM

1. General Information

• Company Identifying InformationCompany Legal Name: Anthem Health Plans, Inc.

Market: IndividualEffective Date: January 1, 2016

• Company Contact InformationPrimary Contact Name: John Bryson

State: ConnecticutHIOS Issuer ID: 86545NAIC Company Code: 60217

The purpose of this rate filing is to establish rates that are reasonable relative to the benefits provided and to demonstrate compliance with state laws and provisions of the Affordable Care Act (ACA). The rates will be in-force for effective dates on or after January 1, 2016. These rates will apply to plans offered both On-Exchange and Off-Exchange. This rate filing is not intended to be used for other purposes.

Policy Form Number(s):HIX_CT_HMO_HSA_(1/16)CT_OFF_HIX_HM_HS_(1/16)CT_HIX_PP_HS_(1/16)

Primary Contact Telephone Number: (203) 677-8026Primary Contact Email Address: [email protected]

2. Scope and Purpose of the Filing

This filing for Anthem Health Plans, Inc., also referred to as Anthem, complies with the most recent regulations and related guidance. To the extent relevant rules or guidance on the rules are updated or changed, amendments to this filing may be required.

CT_OFF_HIX_PP_HS_(1/16)3. Introduction

This filing includes product average rate increase of 6.7% with range by product between 4.1% and 10.1%, and by plan from 3.6% to 11.1%. More details are provided below in Section 4: Proposed Rate Increase.

Emerging single risk pool experience has been used to develop the current rates, while previous rates were developed assigning full credibility to the manual rates.


Factors that affect the proposed rate change for all plans include:

Lower claims cost in the experience: We have included emerging 2014 ACA experience in the rate development.

Medical Trend: The underlying claim costs are expected to increase year over year due to inflation, advancing medical technology and techniques, and increased utilization and cost-shifting.

Morbidity: There are anticipated changes in the market-wide morbidity of the covered population in the projection period.

Benefit modifications and plan design changes.

Changes in taxes, fees, and non-benefit expenses. These include changes in payments from and contributions to the Federal Transitional Reinsurance Program.

4. Proposed Rate Increase

These rate changes by plan are shown in Exhibit I: Non-Grandfathered Rate Changes.

5. Experience Period Premium and Claims

Experience shown in Worksheet 1, Section I of the Unified Rate Review Template is for Connecticut Individual non-grandfathered, single risk pool compliant policies. The information shown is for the identified legal entity only.

Claims experience in Worksheet 1, Section I of the Unified Rate Review Template reflects dates of service from January 1, 2014 through December 31, 2014.

• Paid Through Date

Claims shown in Worksheet 1, Section I of the Unified Rate Review Template are paid through March 31, 2015.

Anticipated changes due to network contracting.

Although rates are based on the same experience, proposed rate changes vary by plan from 3.6% to 11.1%. Factors that affect the variation in the proposed rate changes by plan include:

Changes in benefit design that vary by plan

Updated measurement of relative benefits between plans

Changes in the adjustment factor for Catastrophic eligibility

Changes in Non-Benefit Expenses that are applied on a PMPM basis

• Allowed and Incurred Claims Incurred During the Experience Period

The allowed claims are determined by subtracting non-covered benefits, provider discounts, and coordination of benefits amounts from the billed amount.

The estimated Non-Grandfathered gross earned premium for Connecticut Individual is $286,373,832, where earned premium is the pro-rata share of premium owed to Anthem due to subscribers actively purchasing insurance coverage during the experience period.

The preliminary MLR Rebate estimate is $0, which is consistent with the December 31, 2014 Anthem general ledger estimate allocated to the Non-Grandfathered portion of Individual. Note that this is an estimate and will not be final until 7/31/2015. Using this MLR estimate, the net earned premium for Connecticut Individual is $286,373,832 as shown in cell F14 of Worksheet 1, Section I of the Unified Rate Review Template.

6. Benefit Categories

The methodology used to determine benefit categories in Worksheet 1, Section II of the Unified Rate Review Template is as follows:

Inpatient Hospital: Includes non-capitated facility services for medical, surgical, maternity, mental health and substance abuse, skilled nursing, and other services provided in an inpatient facility setting and billed by the facility.

Outpatient Hospital: Includes non-capitated facility services for surgery, emergency room, lab, radiology, therapy, observation and other services provided in an outpatient facility setting and billed by the facility.

Allowed and incurred claims are completed using the chain ladder method, an industry standard, by using historic paid vs. incurred claims patterns. The method calculates historic completion percentages, representing the percent of claims paid for a particular month after one month of run out, two months, etc. Claim backlog files are reviewed on a monthly basis and are accounted for in the historical completion factor estimates.

Allowed and incurred claims shown in Worksheet 1, Section I of the Unified Rate Review Template are $343,235,845 and $261,173,649, respectively. These amounts differ from those shown in Exhibit B: Claims Experience for Rate Developments due to the Unified Rate Review Template taking Non-ACA plans and Rx Rebates into account.

Additional information can be found on Exhibit B: Claims Experience for Rate Developments.

• Premiums (net of MLR Rebate) in Experience Period

Professional: Includes non-capitated primary care, specialist, therapy, the professional component of laboratory and radiology, and other professional services, other than hospital-based professionals whose payments are included in facility fees.

Other Medical: Includes non-capitated ambulance, home health care, DME, prosthetics, supplies, vision exams, and dental services.

Capitation: Includes all services provided under one or more capitated arrangements.

• Changes in the Morbidity of the Population Insured

Morbidity changes include the following (for Morbidity factor, see Exhibit D: Projection Period Adjustments):

Individuals no longer qualifying for Medicaid

Higher morbidity of the uninsured compared to the insured population: This adjustment is based on a CDC study on the health status and life styles of both currently insured and uninsured populations. This adjustment also considers the expected number of previously uninsured individuals expected to move into the Individual market in 2016.

Individuals losing employer coverage

Individuals converting from Anthem Non-ACA policies

Prescription Drug: Includes drugs dispensed by a pharmacy and rebates received from drug manufacturers.

7. Projection Factors

The experience in Worksheet 1, Section I of the Unified Rate Review Template is brought into the projection period using the factors described below.

Individuals electing to drop coverage

The movement assumptions above are based on market research and assumptions on the retention and sales rates. The morbidity impacts of population movement are based on health status determined from internal risk score data.

Pent-up demand adjustment: As previously uninsured individuals obtained insurance in 2014, Anthem expected them to have some pent-up demand for health care services in year one. This pent-up demand impact is captured in our 2014 experience and Anthem does not expect this additional utilization to continue in 2016. Therefore, an adjustment has been made to back-out the additional utilization in 2014 that was attributed to pent-up demand.

Our goal is to price to the average risk of the 2016 ACA market. Since Anthem-specific experience was used as a starting point, we adjusted this experience to be more consistent with the overall market in Connecticut. Wakely Consulting collected demographic and risk information from carriers, and calculated Anthem's relative risk to the market for 2014. We have adjusted our starting experience using the results of that survey, as shown in line item 4 of Exhibit A: Market Adjusted Index Rate Development.

• Changes in Benefits

Benefit changes include the following:

Rx Adjustments: The claims are adjusted for differences in the Rx formulary and the impact of moving drugs into different tiers in the projection period relative to what is reflected in the base experience data as shown in Exhibit D: Projection Period Adjustments.

• Changes in Demographics

The experience data was normalized to reflect anticipated changes in age/gender, area, network, and benefit plan from the experience period to the projection period. The purpose of these factors is to adjust current experience to be reflective of expected claim experience in the projection period. See Section 22: Membership Projections for additional information on membership movement. The normalization factors and their aggregate impact on the underlying experience data are detailed in Exhibit C: Normalization Factors.

Age/Gender: The assumed claims cost is applied by age and gender to the experience period distribution and the projection period distribution.

Area/Network: The area claims factors are developed based on an analysis of Individual allowed claims by network, mapped to the prescribed 2016 rating areas using the subscriber's 5-digit zip code.

Benefit Plan: The experience period claims are normalized to an average 2016 plan using benefit relativities. The benefit relativities include the value of cost shares and anticipated changes in utilization due to the difference in average cost share requirements.

• Other Adjustments

For members active less than 12 months of the experience period, claims were adjusted using company specific seasonality and maturation factors.

The impact of this analysis is reflected in the "Seasonality" adjustment factor of 1.0068 shown in line 2 of Exhibit A: Market Adjusted Index Rate Development.

Induced Demand Due to Cost Share Reductions: Individuals below 250% Federal Poverty Level who enroll in silver plans On-Exchange will be eligible for cost share reductions. The base period experience has higher anticipated utilization built-in as CSR plans were made available in 2014. As a result, the 2016 utilization impact is calculated based on the projected change in silver plans On-Exchange membership. Anthem used the HHS-promulgated factors for the Induced Demand Utilization factors.

Grace Period: The base period experience may be adjusted upward to account for some incidence of enrollees not paying premiums due during the first month of the 90-day grace period when the QHP is liable for paying claims. Based on 2014 experience this adjustment is 1.0024.

Change in Medical Management: medical management savings not already included in the claims experience and trend.

Change in Provider Contracts: anticipated changes in provider contracts are reflected in the plan level adjustments and the region rating factors.

The cost of pediatric dental and vision benefits are included, as can be found in Exhibit E: Other Claim Adjustments.

Rx Rebates: The projected claims cost is adjusted to reflect anticipated Rx rebates. These projections take into account the most up-to-date information regarding anticipated rebate contracts, drug prices, anticipated price inflation, and upcoming patent expirations.

• Trend Factors (cost/utilization)

The annual pricing trend used in the development of the rates is 7.6%. The trend is developed by normalizing historical Small Group benefit expense for changes in the underlying population and known cost drivers, which are then projected forward to develop the pricing trend. Examples of such changes include contracting, cost of care initiatives, workdays, costs associated with Hepatitis C, compound drugs, average wholesale price, and expected introduction of generic drugs. Small Group benefit expense was used as the basis for the Individual trend development because there is not enough historical Individual ACA data to develop a credible trend analysis. The trend includes a volatility provision in accordance with Actuarial Standards of Practice. The claims are trended 23.6 months from the midpoint of the experience period, which is July 12, 2014, to the midpoint of the projection period, which is July 1, 2016. The mid-point of the experience period is shifted later than July 1, 2014 due to staggered open enrollment in 2014. Additional information can be found in Exhibit D: Projection Period Adjustments.

Projected trends include the estimated cost of the pharmaceutical Sovaldi and other high-cost drugs for treating Hepatitis C. These cost estimates were based on claims experience, together with CDC recommendations, Industry and Anthem Inc. data.

• Resulting Credibility Level Assigned to Base Period Experience

8. Credibility Manual Rate Development

Anthem is assigning 100% credibility to the single risk pool experience. Therefore, a manual rate was not required in the development of these rates.

9. Credibility of Experience

• Description of the Credibility Method Used

Based on an analysis of historical data, the standard for fully credible experience is 6,277 members.

To determine credibility, the following formula was used:

�𝐸𝑥𝑝𝑒𝑟𝑖𝑒𝑛𝑐𝑒 𝑃𝑒𝑟𝑖𝑜𝑑 𝑀𝑒𝑚𝑏𝑒𝑟𝑠

6,277

With 43,931 members, the credibility level assigned to the experience in Worksheet 1, Section II of the Unified Rate Review Template is 100%.

10. Paid to Allowed Ratio

The ‘Paid to Allowed Average Factor in Projection Period’ shown in Worksheet 1, Section III of the Unified Rate Review Template is developed by membership-weighted essential health benefit paid claims divided by membership-weighted essential health benefit allowed claims of each plan. The projected membership by plan is shown in Worksheet 2, Section II of the Unified Rate Review Template.

11. Risk Adjustment and Reinsurance

• Experience Period Risk Adjustment and Reinsurance

The transitional reinsurance risk mitigation program collects funds from all insurance issuers and TPAs and redistributes them to high cost claimants in the Non-Grandfathered Individual market. The reinsurance contribution is equal to the national per capita reinsurance contribution rate as shown in Exhibit F: Risk Adjustment and Reinsurance - Contributions and Payments.

The reinsurance payment is developed using actual 2014 reinsurance experience, projected paid claims, claim probability distribution, and reinsurance payment guidelines. The claim probability distribution observes claims between $90,000 and $250,000 using a claim probability distribution that reflects the anticipated claim cost distribution of the 2016 Individual market. The coinsurance rate is 50%. Expected paid claims are calculated for an assumed average On-Exchange plan design. Reinsurance payments are allocated proportionally by plan premiums to all plans in the risk pool.

Wakely Consulting collected demographic and risk information from carriers, and calculated Anthem's relative risk to the market for 2014. Experience period risk adjustment transfers were based on the results of that survey.

Experience period reinsurance recoveries were based on expected recoveries as of December 31, 2014, plus PPIA that was recognized through March 2015.

• Projected Risk Adjustments

The Risk Adjustment program transfers funds from lower risk plans to higher risk plans in the Non-Grandfathered Individual and Small Group market. The HHS operated Risk Adjustment program is supported by a user fee, as shown in Exhibit F: Risk Adjustment and Reinsurance - Contributions and Payments.

Anthem is assuming a risk transfer payment of ($0.43), as shown in Exhibit F: Risk Adjustment and Reinsurance - Contributions and Payments.

• Projected ACA Reinsurance Recoveries Net of Reinsurance Premium

12. Non-Benefit Expenses, Profit and Risk

Non-Benefit expenses are detailed in Exhibit G: Non-Benefit Expenses and Profit & Risk.

• Administrative Expense

Administrative Expense contains both acquisition costs associated with the production of new business through non-broker distribution channels (direct, telesales, etc) as well as maintenance costs associated with ongoing costs for the administration of the business. Acquisition costs are projected using historical cost per member sold amounts applied to future sales estimates. Maintenance costs are projected for 2016 based on 2014 actual expenses, with adjustments for expected changes in business operations including new expenses for risk management, regulatory compliance and premium reconciliation and balancing.

Selling Expense represents broker commissions and bonuses associated with the broker distribution channel using historical and projected commission levels. Commissions will be paid both On-Exchange and Off-Exchange.

• Taxes and Fees

Patient-Centered Outcomes Research Institute (PCORI) Fee: The PCORI fee is a federally-mandated fee designed to help fund the Patient-Centered Outcomes Research Trust Fund. For plan years ending on or after October 1, 2014, and before October 1, 2015, the fee is $2.08 per member per year. Thereafter, for every plan year ending before October 1, 2019, the fee will increase by the percentage increase in National Healthcare Expenditures.

• Miscellaneous Item

The miscellaneous items represent DOI fees and assements, including the assessment from the State of Connecticut to cover the cost of the Vaccine Immunization Program which provides immunizations for all Connecticut residents.

• Quality Improvement Expense

The quality improvement expense represents Anthem's dedication to providing the highest standard of customer care and consistently seeking to improve health care quality, outcomes and value in a cost efficient manner.

The QI Expense assumptions are based on historical amounts related to the following initiatives: Improve Health Outcomes, Activities to Prevent Hospital Readmissions, Improve Patient Safety and Reduce Medical Errors, Wellness and Health Promotion Activities, HIT Expenses for Health Care Quality Improvements, and ICD-10.

• Selling Expense

ACA Insurer Fee: The health insurance industry will be assessed a permanent fee, based on market share of net premium, which is not tax deductible. The tax impact of non-deductibility is captured in this fee.

Exchange Fee: The Exchange User Fee applies to Exchange business only, but the cost is spread across all Individual plans. The expected charge is estimated at 1.35% of Total Individual Premium. The resulting fee/percentage is applied evenly to all plans in the risk pool, both On and Off Exchange.

Premium taxes, federal income taxes, and state income taxes are also included in the retention items.

The Anthem Index Rate for Individual business in Connecticut is based on total combined claims costs for providing essential health benefits within the single risk pool of non-grandfathered Individual plans in Connecticut. The Index Rate is adjusted on a market-wide basis for the state based on the total expected market-wide payments and charges under the risk adjustment and reinsurance programs and Exchange user fees. The premium rates for all Anthem non-grandfathered plans in the Individual market use the applicable market-wide adjusted index rate, subject only to the permitted plan-level adjustments. This demonstrates that the Single Risk Pool for Anthem Individual business is established according to the requirements in 45 CFR part 156, §156.80(d).

• Profit

Profit is reflected on a post-tax basis as a percent that does not vary by product or plan. The profit percentage does not include any assumed risk corridor payments or receipts.

13. Projected Loss Ratio

• Projected Federal MLR

The projected Federal MLR for the products in this filing is estimated in Exhibit M: Federal MLR Estimated Calculation. Please note that this calculation is purely an estimate and not meant to be a true measure for Federal or State MLR rebate purposes. The MLR for Anthem's entire book of Individual business will be compared to the minimum Federal benchmark for purposes of determining regulation-related premium refunds. Also note that the projected Federal MLR presented here does not capture all adjustments, including but not limited to: three-year averaging, credibility, dual option, and deductible. Anthem's projected MLR is expected to meet or exceed the minimum MLR standards at the market level after including all adjustments.

14. Single Risk Pool

15. Index Rate

• Experience Period Index Rate

The index rate represents the average allowed claims PMPM of essential health benefits for Anthem's Individual Non-Grandfathered Business. The experience period index rate shown in Worksheet 1, Section I (cell G17) of the Unified Rate Review Template is $502.00.

• Projection Period Index Rate

The index rate represents the average allowed claims PMPM of essential health benefits for Anthem's Individual Non-Grandfathered Business. The projection period index rate was developed as shown in Exhibit A: Market Adjusted Index Rate Development by adjusting the projected incurred claims PMPM as described in Section 7: Projection Factors of this memorandum. Covered benefits in excess of essential health benefits that are included in the projection period allowed claims (cell V32 of Worksheet 1, Section II of the Unified Rate Review Template) are elective abortion. No benefits in excess of the essential health benefits are included Exhibit A: Market Adjusted Index Rate Development's projection period index rate (also shown in cell V44 of Worksheet 1, Section III of the Unified Rate Review Template).

Provider Network Adjustments: This is a multiplicative factor that adjusts for differences in projected claims cost due to different network discounts.

Adjustments for Benefits in Addition to EHBs: This multiplicative factor adjusts for additional benefits that are not EHBs.

Adjustments for Administrative Cost: This is an additive adjustment that includes all the Selling Expense, Administration and Retention Items shown in Exhibit G: Non-Benefit Expenses and Profit & Risk, with the exception of the Exchange User Fee since it is already included in the Market Adjusted Index Rate.

16. Market Adjusted Index Rate

The Market Adjusted Index rate is calculated as the Index Rate adjusted for all allowable market wide modifiers defined in the market rating rules. This development is presented in Exhibit A: Market Adjusted Index Rate Development.

17. Plan Adjusted Index Rate

The Plan Adjusted Index Rate is calculated as the Market Adjusted Index Rate adjusted for all allowable plan level modifiers defined in the market rating rules. This development is presented in Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates.

• Plan Level Modifiers

Cost Sharing Adjustments: This is a multiplicative factor that adjusts for the projected paid/allowed ratio of each plan, based on the AV metal value with an adjustment for utilization differences due to differences in cost sharing.

Catastrophic Factor: This adjustment assumes a healthier than average population will select the catastrophic plan. The catastrophic adjustment factor is only applied to catastrophic plans, as shown in Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates.

18. Calibration

The required premium in the projection period is calibrated by the average rating calibration factors (Age and Area), which are used to develop the Consumer Adjusted Premium Rates. The average rating factors are shown in Exhibit H: Calibration, Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates.

The Consumer Adjusted Premium Rate is calculated as the Plan Adjusted Index Rate calibrated as described in the previous section. This development is presented in Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates. The calibration is shown in Exhibit H: Calibration.

20. Actuarial Value Metal Values

The Actuarial Value (AV) Metal Values included in Worksheet 2 of the Unified Rate Review Template are based on the AV Calculator. To the extent a component of the benefit design was not accommodated by an available input within the AV Calculator, the benefit characteristic was adjusted to be actuarially equivalent to an available input within the AV Calculator for purposes of utilizing the AV Calculator as the basis for the AV Metal Values. Benefits for plans that are not compatible with the parameters of the AV Calculator have been separately identified and documented in the Unique Plan Design Supporting Documentation and Justification that supports the Plan & Benefits Template.

• Age Factors

Refer to Exhibit J: Age and Tobacco Factors.

The average age rating factor shown in Exhibit H: Calibration is calculated as a member-weighted average of the age rating factors, using the projected age distribution assumptions in our pricing model, with an adjustment for the maximum of 3 child dependents under age 21. Using the same methodology, the approximate average age rounded to the nearest whole number for the associated risk pool is 49.

• Area Factors


19. Consumer Adjusted Premium Rate

21. Actuarial Value Pricing Values

The Actuarial Value (AV) Pricing Values for each Plan ID are in Worksheet 2, Section I of the Unified Rate Review Template. The AV Pricing Value represents the cumulative effect of adjustments made by the issuer to move from the Market Adjusted Index Rate to the Plan Adjusted Index Rate. Consistent with final Market rules, utilization adjustments are made to account for member behavior variations based upon cost-share variations of the benefit design and not the health status of the member. The average allowable modifiers to the Index Rate can be found in Exhibit N: Plan Adjusted Index Rate and Consumer Adjusted Premium Rates.

22. Membership Projections

The projected morbidity changes shown in Exhibit D: Projection Period Adjustments include expected morbidity changes due to population movement.

Cost share reduction subsidies will be available on silver level plans. Anthem ran projections to estimate enrollment by income level in each of the plans. Projected enrollment by plan and subsidy level can be found in Exhibit P: Membership Projections for Cost-Sharing Reductions.

23. Warning Alerts

There are warning alerts in cells A54 and A56 on Worksheet 2, Section III of the Unified Rate Review Template. This is because Plan Adjusted Index Rates are only entered for single risk pool compliant plans on Worksheet 2, whereas the Worksheet 1 average premium rate reflects the experience of all non-grandfathered (single risk pool compliant and non-ACA) policies. An additional impact is due to differences in the distribution of ages, geography, and benefits that was projected when developing rates versus what actually emerged

Membership projections in Worksheet 2 of the Unified Rate Review Template are developed using a population movement model plus adjustments for sales expectations. This model projects the membership in the projection period by taking into account:

Uninsured to Individual as a result of guaranteed issue, subsidized coverage, and individual mandate

Small Group to Individual as a result of guaranteed issue and Small Group insuring decisions

High Risk Pools to Individual as a result of guaranteed issue

Individual and Uninsured to Medicaid as a result of expanded Medicaid eligibility

The plan distribution is based on assumed metal tier and network distributions. Some 2015 preliminary enrollment information has been considered in projecting membership distributions.

24. Terminated Products

There are no terminated products. Exhibit O: Terminated Products

(1) The projected Index Rate is:

In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.80(d)(1))

Developed in compliance with the applicable Actuarial Standards of Practice

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

Not excessive, deficient, or unfairly discriminatory.

(2) 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.

25. Plan Type

Plan types in Worksheet 2, Section I of the URRT adequately describe Anthem's plans.

26. Reliance

In support of this rate development, various data and analyses were provided by other members of Anthem's internal actuarial staff, including data and analysis related to cost of care, valuation, and pricing. I have reviewed the data and analyses for reasonableness and consistency. I have relied on Wakely Consulting to provide the actuarial certification for the Unique Plan Design Supporting Documentation for the On Exchange Standard plans required by the Connecticut state exchange. I have also relied on Michele Archer, FSA, MAAA to provide the actuarial certification for the Unique Plan Design Supporting Documentation and Justification for the other plans included in this filing.

27. Actuarial Certification

I, John Bryson, ASA, MAAA, am an actuary for Anthem. I am a member of the American Academy of Actuaries and an Associate of the Society of Actuaries. I meet the Qualification Standards of the American Academy of Actuaries to render the actuarial opinion contained herein. I hereby certify that the following statements are true to the best of my knowledge with regards to this filing:

(3) The percent of total premium that represents essential health benefits included in Worksheet 2, Sections III and IV of the Part I Unified Rate Review Template is calculated in accordance with Actuarial Standards of Practice.

(4) The geographic rating factors reflect only differences in the costs of delivery (which can include unit cost and provider practice pattern differences) and do not include differences for population morbidity by geographic area.

John Bryson, ASA, MAAAActuary & Director I

April 30, 2015Date

(5) The most recent 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.

The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the rates. Rather it represents information required by Federal regulation to be provided in support of the review of rate changes, for certification of Qualified Health Plans for Federally-Facilitated Exchanges, and for certification that the Index Rate is developed in accordance with Federal regulation, used consistently, and only adjusted by the allowable modifiers. However, this Actuarial Memorandum does accurately describe the process used by the issuer to develop the rates.

Experience Rate1) Starting Paid Claims PMPM 448.59$ Exhibit B2) x Seasonality 1.0068 3) x Wakely Adjustment {1} 0.9294 4) Mature Claims PMPM 419.75$ = (1) x (2) x (3)

5) x Normalization Factor 0.9536 Exhibit C6) = Normalized Claims 400.27$ = (4) x (5)

7) x Benefit Changes 1.0007 Exhibit D8) x Morbidity Changes 0.9336 Exhibit D9) x Trend Factor 1.1545 Exhibit D

10) x Other Cost of Care Impacts 0.9996 Exhibit D11) Projected Paid Claim Cost 431.56$ = (6) x (7) x (8) x (9) x (10)

12) Credibility Weight 100%13) Blended Paid Claims $431.5614) - Non-EHBs Embedded in Line Item (1) Above $0.9815) = Projected Paid Claims, Excluding ALL Non-EHBs $430.5816) + Rx Rebates -$10.56 Exhibit E17) + Additional EHBs {2} $4.01 Exhibit E18) = Projected Paid Claims Reflecting only EHBs $424.0319) ÷ Paid to Allowed Ratio 0.7991020) = Projected Allowed Claims Reflecting only EHBs $530.63 = Index Rate

21) Reinsurance Contribution $2.25 Exhibit F22) Expected Reinsurance Payments -$34.85 Exhibit F23) Risk Adjustment Fee $0.15 Exhibit F24) Risk Adjustment Net Transfer -$0.43 Exhibit F25) Exchange Fee $6.6326) Market Adjusted Index Rate {3} $497.78 = [(18)+(21)+(22)+(23)+(24)+(25)] ÷ (19)

Notes:{1} Adjustment based on Wakely survey to bring starting experience in-line with the market{2} Pediatric Dental and Pediatric Vision{3} The Market Adjusted Index Rate is the same for all plans in the single risk pool

Exhibit A - Market Adjusted Index Rate Development



CSR Total Member TotalMedical Drug Medical Drug Medical Drug Capitation Receivable Benefit Expense Months PMPM194,410,535$ 41,176,361$ 13,988,977$ 20,823$ 208,399,512$ 41,197,184$ -$ (13,115,992)$ 236,480,704$ 527,166 448.59$

CSR Total Member TotalMedical Drug Medical Drug Medical Drug Capitation Receivable Benefit Expense Months PMPM234,966,958$ 51,258,059$ 16,520,160$ 24,377$ 251,487,118$ 51,282,436$ -$ N/A 302,769,555$ 527,166 574.33$

Notes:

ALLOWED CLAIMS:

Exhibit B - Claims Experience for Rate Developments


Experience Rate Claims ExperienceIncurred January 1, 2014 through December 31, 2014


PAID CLAIMS:Incurred and Paid Claims: IBNR: Fully Incurred Claims:

The claims shown above in the Experience Rate Claims Experience do not account for Non-ACA Plans or Rx Rebates; whereas, the claims shown in Worksheet 1, Section 1 of the Unified Rate Review Template do include those pieces.Drug Claims are processed by an external vendor.

Incurred and Paid Claims: IBNR: Fully Incurred Claims:

Experience Period Population

Future Population

Normalization Factor

Age/Gender 1.0432 1.0314 0.9887Area/Network 0.9122 0.9204 1.0090Benefit Plan 0.6895 0.6591 0.9559Total 0.9536

Exhibit C - Normalization Factors



Average Claim Factors - Experience Rate

Experience RateBenefit changes

Rx Adjustments {1} 1.0007Total Benefit Changes 1.0007

Morbidity changesTotal Morbidity Changes 0.9336

Cost of care impactsAnnual Medical/Rx Trend Rate 7.57%# Months of Projection 23.63Trend Factor 1.1545

Medical Management 1.0002Induced Demand for CSR 0.9970Grace Period 1.0024Total other Impacts 0.9996

Notes:

{1} Includes Rx formulary and impacts for moving drugs into different tiers

Exhibit D - Projection Period Adjustments



Impact of Changes Between Experience Period and Projection Period:

PMPMRx Rebates ($10.56)Pediatric Dental $3.53Pediatric Vision $0.48Total ($6.55)

Notes:Adjustments above reflect ONLY additional costs beyond those already captured in line Item 15 of Exhibit A.

Exhibit E - Other Claim Adjustments



Adjustments to projection period claims to reflect covered benefits not included in experience period data:

Risk Adjustment:PMPM User Fee Net Transfer Federal Program $0.15 ($0.43)

Reinsurance:

PMPM Contributions Made Expected Receipts

Federal Program $2.25 ($34.85)

Source:

Grand Total of All Risk Mitigation Programs ($32.88)

HHS estimates a national per capita contribution rate of $2.25 per month ($27 per year) in benefit year 2016 (per Payment Parameter Rule).

Exhibit F - Risk Adjustment and Reinsurance - Contributions and Payments



Expenses Applied As a PMPM Cost

Expenses Applied as a % of Premium

Expressed as a PMPM {1}

Administrative ExpensesAdministrative Costs $30.54Quality Improvement Expense $3.61Selling Expense 1.20%Specialty Expenses $0.62Misc Admin (PMPM) {2} $1.47

Total Administrative Expenses $36.24 1.20% $42.14Taxes and Fees

PCORI Fee $0.18ACA Insurer Fee 2.90%Exchange Fee 1.35%Premium Tax 1.75%MLR-Deductible Federal/State Income Taxes {3} 1.75%Misc Taxes & Fees (% prem) {4} 0.53%

Total Taxes and Fees $0.18 $0.08 $40.83Profit and Risk {5} 3.25% $15.96Total Non-Benefit Expenses, Profit, and Risk $36.42 12.73% $98.92

Notes:

{3} Includes only those income taxes which are deductible from the MLR denominator; in particular, Federal income taxes on investment income are excluded.{4} Includes charges for DOI Fees and Assessments{5} Profit shown here is post-tax profit, net of those federal and state income taxes which are deductible from the MLR denominator.

Exhibit G - Non-Benefit Expenses and Profit & Risk



{1} The sum of the rounded percentages shown may not equal the total at the bottom of the table due to rounding.{2} Includes charge for State of Connecticut Vaccine Immunization Program.

Calibration FactorsAge 1.6725Area 0.9598Total Calibration Factor 1.6052

Notes:

When computing family premiums, no more than the three oldest covered children under the age of 21 are taken into account, whereas the premiums associated with each child age 21+ are included. As such, the average rating factor was adjusted to reflect the portion of the population under age 21 for which the calibration can be made.

Exhibit H - Calibration



Average 2016 rating factors for 2016 population:

See Calibration Factor on Exhibit N.

1







Notes:





Age Factors Tobacco FactorsAge 2016 20160-17 0.635 1.00018 0.635 1.00019 0.635 1.00020 0.635 1.00021 1.000 1.00022 1.000 1.00023 1.000 1.00024 1.000 1.00025 1.004 1.00026 1.024 1.00027 1.048 1.00028 1.087 1.00029 1.119 1.00030 1.135 1.00031 1.159 1.00032 1.183 1.00033 1.198 1.00034 1.214 1.00035 1.222 1.00036 1.230 1.00037 1.238 1.00038 1.246 1.00039 1.262 1.00040 1.278 1.00041 1.302 1.00042 1.325 1.00043 1.357 1.00044 1.397 1.00045 1.444 1.00046 1.500 1.00047 1.563 1.00048 1.635 1.00049 1.706 1.00050 1.786 1.00051 1.865 1.00052 1.952 1.00053 2.040 1.00054 2.135 1.00055 2.230 1.00056 2.333 1.00057 2.437 1.00058 2.548 1.00059 2.603 1.00060 2.714 1.00061 2.810 1.00062 2.873 1.00063 2.952 1.000

64+ 3.000 1.000

Notes:

Exhibit J - Age and Tobacco Factors



The weighted averages of these factors for the entire risk pool included in this rate filing is detailed in Exhibit H.

Rating Area Description

2016 Area Rating Factor

2015 Area Rating Factor Change

Fairfield 1.1000 1.1000 0.0%Hartford 0.8700 0.8700 0.0%Litchfield 0.8700 0.8700 0.0%

Middlesex 0.9500 0.9500 0.0%New Haven 0.9500 0.9500 0.0%

New London 0.8700 0.8700 0.0%Tolland 0.8700 0.8700 0.0%

Windham 0.8700 0.8700 0.0%

Notes:The weighted average of these factors for the entire risk pool included in this rate filing is detailed in Exhibit H.

Exhibit K - Area Factors



Name: John DoeEffective Date: 1/1/2016On/Off Exchange: OffMetal Level: BronzePlan ID: 86545CT1310019Rating Area: 01

Family Members Covered:Age

Subscriber 47Spouse 42

Child (age 21+) 25Child #1 20Child #2 16

Calculation of Monthly Premium:Consumer Adjusted Premium Rate $ 243.97 Exhibit Nx Area Factor 1.1000 Exhibit KRate Adjusted for Area = $ 268.37

Age Factors Exhibit J:Age Factor

Subscriber 1.563Spouse 1.325

Child (age 21+) 1.004Child #1 0.635Child #2 0.635

Final Monthly Premium PMPM:PMPM

Subscriber 419.46$ Spouse 355.59$

Child (age 21+) 269.44$ Child #1 170.41$ Child #2 170.41$ TOTAL 1,385.31$

Notes:

Minor rate variances may occur due to differences in rounding methodology.

As per the Market Reform Rule, when computing family premiums no more than the three oldest covered children under the age of 21 are taken into account whereas the premiums associated with each child age 21+ are included.

Exhibit L - Sample Rate Calculation



Numerator: Incurred Claims 425.01$ Exhibit A (Line 13) + Exhibit E (Total)+ Quality Improvement Expense 3.61$ Exhibit G+ Risk Corridor Contributions -$ + Risk Adjustment Net Transfer (0.43)$ Exhibit F+ Reinsurance Receipts (34.85)$ Exhibit F+ Risk Corridor Receipts -$ + Reduction to Rx Incurred Claims (ACA MLR) (6.87)$ {1}= Estimated Federal MLR Numerator 386.47$

Denominator: Premiums 491.05$ Incurred Claims + Exhibit F (Total) + Exhibit G (Total)- Federal and State Taxes 8.59$ Premiums x Exhibit G (Income Taxes)- Premium Taxes 8.59$ Premiums x Exhibit G (Premium Tax)- Risk Adjustment User Fee 0.15$ Exhibit F- Reinsurance Contributions 2.25$ Exhibit F- Misc Admin (PMPM) 1.47$ Exhibit G- Misc Taxes & Fees (% of Premium) 2.59$ Exhibit G- Licensing and Regulatory Fees $21.05 Premiums x Exhibit G (Fees)= Estimated Federal MLR Denominator 446.36$

Estimated Federal MLR 86.58%

Notes:

{1} This is the percentage of 2016 pharmacy claims that are attributable to PBM Administrative Expenses (i.e. the "retail spread" or "pharmacy claims margin"). It is calculated by applying the 3rd party margin percentage to the 2016 projected Pharmacy claims including projected rebates.

Exhibit M - Federal MLR Estimated Calculation



The above calculation is purely an estimate and not meant to be compared to the minimum MLR benchmark for federal/state MLR rebate purposes:

* The above calculation represents only the products in this filing. Federal MLR will be calculated at the legal entity and market level.

* Not all numerator/denominator components are captured above (for example, fraud and prevention program costs, payroll taxes, assessments for state high risk pools etc.).

* Other adjustments may also be applied within the federal MLR calculation such as 3-year averaging, new business, credibility, deductible and dual option. These are ignored in the above calculation.

* Licensing and Regulatory Fees include ACA-related fees as allowed under the MLR Final Rule.

HIOS Plan Name HIOS Plan ID

Market Adjusted Index Rate (Exhibit

A)Cost Sharing Adjustment

Provider Network

Adjustment

Adjustment for Benefits in Addition

to the EHBS

Catastrophic Plan Adjustment

{1} Administrative Costs


{2}

Calibration Factor

{3}

Consumer Adjusted Premium Rate

{4}Catastrophic HMO Pathway X Enhanced 86545CT1230005 $497.78 0.5249 0.9645 1.0043 0.8267 $48.72 $257.96 1.6052 $160.70Bronze HMO Pathway X Enhanced for HSA 86545CT1230001 $497.78 0.6021 0.9645 1.0031 1.0000 $67.32 $357.30 1.6052 $222.59Bronze HMO Pathway X Enhanced 86545CT1230002 $497.78 0.6491 0.9645 1.0029 1.0000 $72.50 $385.05 1.6052 $239.88Gold HMO Pathway X Enhanced 86545CT1230004 $497.78 0.9558 0.9645 1.0020 1.0000 $106.33 $566.12 1.6052 $352.68Anthem HMO Catastrophic BlueCare 6850/0% 86545CT1310033 $497.78 0.5248 1.0451 1.0043 0.8267 $52.73 $279.42 1.6052 $174.07Anthem Bronze HMO BlueCare 6000/12000/0% for HSA 86545CT1310019 $497.78 0.6092 1.0451 1.0031 1.0000 $73.73 $391.62 1.6052 $243.97Anthem Bronze HMO BlueCare 6000/0% 86545CT1310024 $497.78 0.6333 1.0451 1.0030 1.0000 $76.61 $407.07 1.6052 $253.59Anthem Bronze HMO BlueCare 6550/13100/0% for HSA 86545CT1310039 $497.78 0.5248 1.0451 1.0036 1.0000 $63.64 $337.62 1.6052 $210.33Anthem Silver HMO BlueCare 3500/7000/0% for HSA 86545CT1310030 $497.78 0.7429 1.0451 1.0025 1.0000 $89.70 $477.17 1.6052 $297.27Anthem Silver HMO BlueCare 3500/0% 86545CT1310031 $497.78 0.7729 1.0451 1.0024 1.0000 $93.28 $496.34 1.6052 $309.21Anthem Silver HMO BlueCare Tiered 3000/3850/0% 86545CT1310040 $497.78 0.6907 1.0451 1.0027 1.0000 $83.47 $443.78 1.6052 $276.46Anthem Gold HMO BlueCare 1500/0% 86545CT1310032 $497.78 0.9557 1.0451 1.0020 1.0000 $115.13 $613.28 1.6052 $382.06Anthem Gold HMO Pathway X Enhanced 1850/0% 86545CT1310035 $497.78 0.9004 0.9645 1.0021 1.0000 $100.20 $533.38 1.6052 $332.28Anthem Gold HMO BlueCare Tiered 2000/3500/0% 86545CT1310043 $497.78 0.8562 1.0451 1.0022 1.0000 $103.23 $549.63 1.6052 $342.41Bronze PPO Standard Pathway X 86545CT1330002 $497.78 0.6428 0.9741 1.0029 1.0000 $72.49 $385.08 1.6052 $239.90Bronze PPO Standard Pathway X for HSA 86545CT1330009 $497.78 0.5834 0.9741 1.0032 1.0000 $65.87 $349.65 1.6052 $217.82Silver PPO Standard Pathway X 86545CT1330001 $497.78 0.8504 0.9741 1.0022 1.0000 $95.63 $508.90 1.6052 $317.03Silver PPO Pathway X 86545CT1330004 $497.78 0.8625 0.9741 1.0022 1.0000 $96.97 $516.12 1.6052 $321.53Gold PPO Standard Pathway X 86545CT1330003 $497.78 1.0257 0.9741 1.0018 1.0000 $115.16 $613.44 1.6052 $382.16Anthem Bronze PPO Century Preferred 5700/11400/20% for HSA 86545CT1340005 $497.78 0.5452 1.0556 1.0035 1.0000 $66.73 $354.21 1.6052 $220.66Anthem Bronze PPO Century Preferred 6850/0% 86545CT1340010 $497.78 0.5165 1.0556 1.0036 1.0000 $63.26 $335.65 1.6052 $209.10Anthem Silver PPO Century Preferred 2750/20% 86545CT1340006 $497.78 0.7512 1.0556 1.0025 1.0000 $91.58 $487.28 1.6052 $303.56Anthem Silver PPO Century Preferred 2500/20% 86545CT1340007 $497.78 0.7697 1.0556 1.0024 1.0000 $93.82 $499.26 1.6052 $311.03Anthem Silver PPO Century Preferred 3000/6000/20% for HSA 86545CT1340011 $497.78 0.6942 1.0556 1.0027 1.0000 $84.70 $450.46 1.6052 $280.63Anthem Silver PPO Century Preferred 3500/7000/10% 86545CT1340014 $497.78 0.6764 1.0556 1.0028 1.0000 $82.55 $438.94 1.6052 $273.45Anthem Silver PPO Century Preferred Tiered 2850/4000/0% 86545CT1340015 $497.78 0.6888 1.0556 1.0027 1.0000 $84.06 $446.97 1.6052 $278.45Anthem Gold PPO Century Preferred 1500/3000/20% for HSA 86545CT1340012 $497.78 0.8953 1.0556 1.0021 1.0000 $108.98 $580.39 1.6052 $361.57Anthem Gold PPO Century Preferred 1750/0% 86545CT1340013 $497.78 0.9543 1.0556 1.0020 1.0000 $116.10 $618.50 1.6052 $385.31Anthem Gold PPO Century Preferred Tiered 1750/3250/0% 86545CT1340016 $497.78 0.8813 1.0556 1.0021 1.0000 $107.29 $571.37 1.6052 $355.95Gold HMO Pathway X Enhanced, a Multi-State Plan 86545CT1470002 $497.78 0.9023 0.9645 1.0000 1.0000 $100.20 $533.38 1.6052 $332.28Silver PPO Pathway X, a Multi-State Plan 86545CT1480002 $497.78 0.8634 0.9741 1.0000 1.0000 $96.86 $515.51 1.6052 $321.15

Notes:

{2} The Plan Adjusted Index Rate is calculated by multiplying the Market Adjusted Index Rate by the AV and cost sharing, provider network, benefits in addition to the EHBs, and catastrophic plan adjustments and then adding the administrative costs. The Plan Adjusted Index Rate can also be described as a Plan Level Required Premium.{3} See Exhibit H - Calibration.{4} The Consumer Adjusted Premium Rate is calculated by dividing the Plan Adjusted Index Rate by 'Calibration Factor'. The Consumer Adjusted Premium Rate can also be described as a Plan Level Base Rate.

Exhibit N - Plan Adjusted Index Rate and Consumer Adjusted Premium Rates



{1} This adjustment assumes a healthier than average population will select the catastrophic plan.

Following are the products that will be terminated prior to the effective date:

HIOS Product ID HIOS Product NameNONE NONE

Post ACA Terminated Plans

Exhibit O - Terminated Products


Effective January 1, 2016

This includes products that have experience included in the URRT during the experience period and any products that were not in effect during the experience period but were made available thereafter.

Silver PlanHIOS Standard Component Plan ID 100-150% 150%-200% 200%-250% Standard

86545CT1310030 0 0 0 3,20086545CT1310031 0 0 0 70086545CT1310040 0 0 0 40086545CT1330001 3,522 3,243 1,895 5,14086545CT1330004 1,148 1,058 618 1,67686545CT1340006 0 0 0 70086545CT1340007 0 0 0 40086545CT1340011 0 0 0 1,00086545CT1340014 0 0 0 40086545CT1340015 0 0 0 40086545CT1480002 179 165 96 260

Exhibit P - Membership Projections for Cost-Sharing Reductions



Projected Membership by Subsidy Level:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

1819

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

3839

40

41

42

43

44

45

46

47

48

49

50

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

Unified Rate Review v2.0.4

Company Legal Name: Anthem Health Plans, Inc. State: CT

HIOS Issuer ID: 86545 Market: IndividualEffective Date of Rate Change(s): 1/1/2016

Market Level Calculations (Same for all Plans)

Section I: Experience period data

Experience Period: 1/1/2014 to 12/31/2014

Experience Period

Aggregate Amount PMPM % of Prem

Premiums (net of MLR Rebate) in Experience Period: $286,373,832 $418.72 100.00%

Incurred Claims in Experience Period $261,173,649 381.87 91.20%

Allowed Claims: $343,235,845 501.86 119.86%

Index Rate of Experience Period $502.00

Experience Period Member Months 683,933

Section II: Allowed Claims, PMPM basis

Experience Period Projection Period: 1/1/2016 to 12/31/2016 Mid-point to Mid-point, Experience to Projection: 24 months

on Actual Experience Allowed

Adj't. from Experience to

Projection Period Projections, before credibility Adjustment Credibility Manual

Benefit Category

Utilization

Description

Utilization per

1,000

Average

Cost/Service PMPM

Pop'l risk

Morbidity Other Cost Util

Utilization per

1,000

Average

Cost/Service PMPM

Utilization

per 1,000

Average

Cost/Service PMPM

Inpatient Hospital Days 339.60 $3,680.62 $104.16 0.934 0.995 1.035 1.015 326.98 $3,922.10 $106.87 0.00 $0.00 $0.00

Outpatient Hospital Visits 1,967.73 950.72 155.90 0.934 0.995 1.035 1.015 1,894.64 1,013.09 159.95 0.00 0.00 0.00

Professional Visits 10,203.54 174.36 148.26 0.934 0.995 1.035 1.015 9,824.58 185.80 152.12 0.00 0.00 0.00

Other Medical Visits 747.53 237.36 14.79 0.934 0.995 1.035 1.015 719.76 252.93 15.17 0.00 0.00 0.00

Capitation Benefit Period 12,000.00 0.00 0.00 0.934 0.995 1.007 1.007 11,355.25 0.00 0.00 0.00 0.00 0.00

Prescription Drug Prescriptions 10,586.11 89.27 78.76 0.934 0.995 1.101 1.050 10,900.75 107.60 97.74 0.00 0.00 0.00

Total $501.86 $531.86 $0.00

After Credibility Projected Period Totals

Section III: Projected Experience: Projected Allowed Experience Claims PMPM (w/applied credibility if applicable) 100.00% 0.00% $531.86 $351,025,517

Paid to Allowed Average Factor in Projection Period 0.799

Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $425.01 $280,504,491

Projected Risk Adjustments PMPM 0.28 184,254

Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $424.73 $280,320,237

Projected ACA reinsurance recoveries, net of rein prem, PMPM 32.60 21,516,000

Projected Incurred Claims $392.13 $258,804,237

Administrative Expense Load 8.58% 42.14 27,811,704

Profit & Risk Load 3.25% 15.96 10,530,917

Taxes & Fees 8.31% 40.83 26,945,579

Single Risk Pool Gross Premium Avg. Rate, PMPM $491.05 $324,092,437

Index Rate for Projection Period $530.63

% increase over Experience Period 17.27%

% Increase, annualized: 8.29%

Projected Member Months 660,000

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.

Annualized Trend

Factors

1 of 5

Product-Plan Data Collection

Company Legal Name: Anthem Health Plans, Inc.

HIOS Issuer ID: 86545

Effective Date of Rate Change(s):

Product/Plan Level Calculations

Section I: General Product and Plan Information

Product Terminated Products

Product ID: 86545CT131

Metal: Catastrophic Catastrophic Bronze Bronze Gold

AV Metal Value 0.000 0.590 0.608 0.609 0.813

AV Pricing Value 0.000 0.518 0.718 0.774 1.137

Plan Type: HMO HMO HMO HMO HMO

Plan Name

2014 Experience

Catastrophic HMO

Pathway X

Enhanced

Bronze HMO

Pathway X

Enhanced for HSA

Bronze HMO

Pathway X

Enhanced

Gold HMO

Pathway X

Enhanced

Plan ID (Standard Component ID): 86545CT1310018 86545CT1230005 86545CT1230001 86545CT1230002 86545CT1230004

Exchange Plan? No Yes Yes Yes Yes

Historical Rate Increase - Calendar Year - 2 0.00%

Historical Rate Increase - Calendar Year - 1 0.00%

Historical Rate Increase - Calendar Year 0 0.00%

Effective Date of Proposed Rates 1/1/2015 1/1/2016 1/1/2016 1/1/2016 1/1/2016

Rate Change % (over prior filing) 0.00% 7.04% 11.08% 4.72% 4.60%

Cum'tive Rate Change % (over 12 mos prior) -999.00% 7.04% 11.08% 4.72% 4.60%

Proj'd Per Rate Change % (over Exper. Period) #DIV/0! -2.86% 13.72% 16.09% 17.06%

Product Threshold Rate Increase % 0.00%

Section II: Components of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM)

Plan ID (Standard Component ID): Total 86545CT1310018 86545CT1230005 86545CT1230001 86545CT1230002 86545CT1230004

Inpatient -$0.45 $0.00 $2.55 $5.57 -$0.11 -$3.67

Outpatient -$0.68 $0.00 $3.82 $8.34 -$0.16 -$5.49

Professional -$0.65 $0.00 $3.63 $7.93 -$0.15 -$5.22

Prescription Drug -$0.42 $0.00 $2.33 $5.10 -$0.10 -$3.36

Other -$0.06 $0.00 $0.36 $0.79 -$0.02 -$0.52

Capitation $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Administration -$5.41 $0.00 -$23.26 -$18.39 -$14.22 -$2.59

Taxes & Fees $31.84 $0.00 $20.60 $26.71 $32.14 $47.47

Risk & Profit Charge $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Total Rate Increase $24.18 $0.00 $10.03 $36.05 $17.39 $26.62

Member Cost Share Increase -$11.39 $0.00 -$4.81 -$28.21 -$16.86 -$11.17

Average Current Rate PMPM $420.42 $0.00 $142.46 $325.37 $368.36 $578.28

Projected Member Months 660,000 0 6,000 36,000 12,000 20,400

Section III: Experience Period Information

Warning Alert Wsht 1 Total Plan ID (Standard Component ID): Total 86545CT1310018 86545CT1230005 86545CT1230001 86545CT1230002 86545CT1230004

WARNING 418.72$ Plan Adjusted Index Rate $341.24 $0.00 $265.55 $314.20 $331.68 $483.63

OK 683,933 Member Months 683,933 156,766 3,246 40,590 14,384 26,645

WARNING $286,373,832 Total Premium (TP) $233,387,957 $0 $861,984 $12,753,432 $4,770,898 $12,886,353

EHB Percent of TP, [see instructions] 99.02% 0.00% 99.68% 99.67% 99.69% 99.79%

state mandated benefits portion of TP that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TP 0.98% 100.00% 0.32% 0.33% 0.31% 0.21%

OK $343,235,845 Total Allowed Claims (TAC) $343,235,845 $42,686,081 $412,739 $12,628,800 $4,145,159 $21,412,890

EHB Percent of TAC, [see instructions] 86.99% 0.00% 100.00% 100.00% 100.00% 100.00% state mandated benefits portion of TAC that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 13.01% 100.00% 0.00% 0.00% 0.00% 0.00%

Allowed Claims which are not the issuer's obligation: $82,062,196 $17,993,072 $218,722 $4,341,255 $1,384,841 $2,848,553Portion of above payable by HHS's funds on

behalf of insured person, in dollars $13,115,992 $0 $0 $46,922 $10,382 $0Portion of above payable by HHS on behalf of

insured person, as % 15.98% 0.00% 0.00% 1.08% 0.75% 0.00%OK $261,173,649 Total Incurred claims, payable with issuer funds $261,173,649 $24,693,010 $194,018 $8,287,545 $2,760,318 $18,564,337

Net Amt of Rein -$58,298,950.87 $0.00 -$32,813.00 -$2,456,419.22 -$858,534.41 -$4,958,494.64

Net Amt of Risk Adj -$18,806,173.31 $0.00 $28,447.47 $5,858,469.48 $1,614,637.71 -$3,012,841.82

OK 381.87$ Incurred Claims PMPM $381.87 $157.52 $59.77 $204.18 $191.90 $696.73

OK 501.86$ Allowed Claims PMPM $501.86 $272.29 $127.15 $311.13 $288.18 $803.64

EHB portion of Allowed Claims, PMPM $436.59 $0.00 $127.15 $311.13 $288.18 $803.64

Section IV: Projected (12 months following effective date)

Warning Alert Wsht 1 Total Plan ID (Standard Component ID): Total 86545CT1310018 86545CT1230005 86545CT1230001 86545CT1230002 86545CT1230004

OK 491.05$ Plan Adjusted Index Rate $491.05 $257.96 $357.30 $385.05 $566.12

OK 660,000 Member Months 660,000 - 6,000 36,000 12,000 20,400

OK $324,092,437 Total Premium (TP) $324,093,000 $0 $1,547,756 $12,862,623 $4,620,568 $11,548,755

EHB Percent of TP, [see instructions] 99.80% 99.61% 99.72% 99.74% 99.82%


than EHB 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TP 0.20% 100.00% 0.39% 0.28% 0.26% 0.18%

OK 351,025,517 Total Allowed Claims (TAC) $351,439,897 $2,059,164 $16,746,828 $5,921,041 $11,431,801

EHB Percent of TAC, [see instructions] 99.80% 99.61% 99.72% 99.74% 99.82%

state mandated benefits portion of TAC that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 0.20% 100.00% 0.39% 0.28% 0.26% 0.18%

Allowed Claims which are not the issuer's obligation $92,637,429 $824,621 $6,481,047 $2,232,794 $2,208,014

Portion of above payable by HHS's funds on

behalf of insured person, in dollars $15,716,286 $0 $0 $0 $0

Portion of above payable by HHS on behalf of

insured person, as % 16.97% #DIV/0! 0.00% 0.00% 0.00% 0.00%

OK 258,804,237 Total Incurred claims, payable with issuer funds $258,802,468 $0 $1,234,543 $10,265,781 $3,688,247 $9,223,787

OK 21,516,000 Net Amt of Rein $21,516,000 $102,636 $853,464 $306,629 $766,836

Net Amt of Risk Adj $184,800 $882 $7,330 $2,634 $6,586

OK 392.13$ Incurred Claims PMPM $392.12 #DIV/0! $205.76 $285.16 $307.35 $452.15

OK 531.86$ Allowed Claims PMPM $532.48 #DIV/0! $343.19 $465.19 $493.42 $560.38

EHB portion of Allowed Claims, PMPM $531.40 #DIV/0! $341.86 $463.89 $492.14 $559.37

Cla

ims

Info

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ion

Pre

miu

m In

form

atio

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laim

s In

form

atio

n

1/1/2016

Pre

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form

atio

nHMO

86545CT123

0.00%

-3.63%

7.32%

7.32%


Company Legal Name:

HIOS Issuer ID:




Product

Product ID:

Metal:

AV Metal Value

AV Pricing Value

Plan Type:

Plan Name

Plan ID (Standard Component ID):

Exchange Plan?

Historical Rate Increase - Calendar Year - 2


Historical Rate Increase - Calendar Year 0

Effective Date of Proposed Rates

Rate Change % (over prior filing)

Cum'tive Rate Change % (over 12 mos prior)

Proj'd Per Rate Change % (over Exper. Period)

Product Threshold Rate Increase %



Inpatient

Outpatient

Professional

Prescription Drug

Other

Capitation

Administration

Taxes & Fees

Risk & Profit Charge

Total Rate Increase

Member Cost Share Increase

Average Current Rate PMPM

Projected Member Months




Member Months

Total Premium (TP)

EHB Percent of TP, [see instructions]


than EHB

Other benefits portion of TP

Total Allowed Claims (TAC)

EHB Percent of TAC, [see instructions] state mandated benefits portion of TAC that are other

than EHB

Other benefits portion of TAC

Allowed Claims which are not the issuer's obligation:Portion of above payable by HHS's funds on

behalf of insured person, in dollarsPortion of above payable by HHS on behalf of

insured person, as % Total Incurred claims, payable with issuer funds

Net Amt of Rein

Net Amt of Risk Adj

Incurred Claims PMPM

Allowed Claims PMPM

EHB portion of Allowed Claims, PMPM




Member Months

Total Premium (TP)



than EHB



EHB Percent of TAC, [see instructions]


than EHB


Allowed Claims which are not the issuer's obligation


behalf of insured person, in dollars


insured person, as %

Total Incurred claims, payable with issuer funds

Net Amt of Rein

Net Amt of Risk Adj


Allowed Claims PMPM


Cla

ims

Info

rmat

ion

Pre

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form

atio

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s In

form

atio

nP

rem

ium

Info

rmat

ion

State: CT

Market: Individual

Catastrophic Bronze Bronze Bronze Silver Silver Silver Gold Gold Gold

0.590 0.612 0.603 0.599 0.706 0.717 0.709 0.813 0.792 0.794

0.561 0.787 0.818 0.678 0.959 0.997 0.892 1.232 1.072 1.104

HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO

Anthem HMO

Catastrophic

BlueCare 6850/0%

Anthem Bronze

HMO BlueCare

6000/12000/0%

for HSA

Anthem Bronze

HMO BlueCare

6000/0%

Anthem Bronze

HMO BlueCare

6550/13100/0%

for HSA

Anthem Silver

HMO BlueCare

3500/7000/0% for

HSA

Anthem Silver

HMO BlueCare

3500/0%

Anthem Silver

HMO BlueCare

Tiered

3000/3850/0%

Anthem Gold HMO

BlueCare 1500/0%

Anthem Gold HMO

Pathway X

Enhanced

1850/0%

Anthem Gold HMO

BlueCare Tiered

2000/3500/0%

86545CT1310033 86545CT1310019 86545CT1310024 86545CT1310039 86545CT1310030 86545CT1310031 86545CT1310040 86545CT1310032 86545CT1310035 86545CT1310043

No No No No No No No No No No

1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016

7.02% 9.38% 5.09% 0.00% 4.93% 5.46% 0.00% 4.60% 4.14% 0.00%

7.02% 9.38% 5.09% -999.00% 4.93% 5.46% -999.00% 4.60% 4.14% -999.00%

-1.43% 13.55% 14.68% #DIV/0! 11.49% 12.32% #DIV/0! 14.90% #DIV/0! #DIV/0!


$2.13 $4.17 $0.02 $0.00 -$2.00 -$3.51 $0.00 -$5.67 -$3.89 $0.00

$3.19 $6.24 $0.02 $0.00 -$3.00 -$5.25 $0.00 -$8.48 -$5.82 $0.00

$3.03 $5.94 $0.02 $0.00 -$2.85 -$5.00 $0.00 -$8.06 -$5.54 $0.00

$1.95 $3.82 $0.01 $0.00 -$1.83 -$3.21 $0.00 -$5.18 -$3.56 $0.00

$0.30 $0.59 $0.00 $0.00 -$0.28 -$0.50 $0.00 -$0.80 -$0.55 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

-$21.89 -$16.19 -$13.71 $0.00 -$8.41 -$5.29 $0.00 $0.43 -$4.51 $0.00

$22.34 $29.30 $32.61 $0.00 $39.75 $45.13 $0.00 $51.45 $45.07 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$11.05 $33.87 $18.98 $0.00 $21.37 $22.38 $0.00 $23.69 $21.20 $0.00

-$5.21 -$29.93 -$18.69 $0.00 -$4.50 $9.59 $0.00 -$12.10 -$8.71 $0.00

$157.39 $361.04 $372.87 $0.00 $433.58 $409.83 $0.00 $514.57 $512.18 $0.00

3,600 21,600 6,000 4,800 38,400 8,400 4,800 58,800 0 4,800


$283.48 $344.90 $354.95 $0.00 $427.98 $441.89 $0.00 $533.76 $0.00 $0.00

1,664 19,833 9,595 0 43,307 12,109 0 63,642 0 0

$471,703 $6,840,313 $3,405,772 $0 $18,534,344 $5,350,821 $0 $33,969,671 $0 $0

100.00% 100.00% 99.12% 0.00% 100.00% 100.00% 0.00% 94.53% 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% 0.88% 100.00% 0.00% 0.00% 100.00% 5.47% 100.00% 100.00%

$304,062 $9,088,409 $3,264,675 $0 $21,999,490 $5,723,130 $0 $35,317,863 $0 $0

100.00% 100.00% 99.34% 0.00% 100.00% 100.00% 0.00% 94.53% 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% 0.66% 100.00% 0.00% 0.00% 100.00% 5.47% 100.00% 100.00%

$175,971 $2,612,407 $1,084,708 $0 $5,173,324 $1,499,791 $0 $5,542,586 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% #DIV/0! 0.00% 0.00% #DIV/0! 0.00% #DIV/0! #DIV/0!$128,091 $6,476,002 $2,179,967 $0 $16,826,165 $4,223,339 $0 $29,775,277 $0 $0

-$5,751.36 -$1,984,828.94 -$683,263.61 $0.00 -$4,330,900.10 -$844,375.06 $0.00 -$6,397,253.04 $0.00 $0.00

$62,269.65 $1,671,447.29 $808,097.28 $0.00 $2,926,701.13 -$95,837.92 $0.00 -$2,819,411.76 $0.00 $0.00

$76.98 $326.53 $227.20 #DIV/0! $388.53 $348.78 #DIV/0! $467.86 #DIV/0! #DIV/0!

$182.73 $458.25 $340.25 #DIV/0! $507.99 $472.63 #DIV/0! $554.95 #DIV/0! #DIV/0!

$182.73 $458.25 $337.99 #DIV/0! $507.99 $472.63 #DIV/0! $524.61 #DIV/0! #DIV/0!


$279.42 $391.62 $407.07 $337.62 $477.17 $496.34 $443.78 $613.28 $533.38 $549.63

3,600 21,600 6,000 4,800 38,400 8,400 4,800 58,800 - 4,800

$1,005,908 $8,458,895 $2,442,450 $1,620,558 $18,323,368 $4,169,219 $2,130,124 $36,060,689 $0 $2,638,210

99.64% 99.74% 99.75% 99.70% 99.79% 99.80% 99.77% 99.84% 99.81% 99.82%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.36% 0.26% 0.25% 0.30% 0.21% 0.20% 0.23% 0.16% 0.19% 0.18%

$1,338,545 $10,925,190 $3,133,955 $2,140,265 $20,906,352 $4,716,831 $2,431,625 $35,698,980 $1 $2,669,686

99.64% 99.74% 99.75% 99.70% 99.79% 99.80% 99.77% 99.84% 99.81% 99.82%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.36% 0.26% 0.25% 0.30% 0.21% 0.20% 0.23% 0.16% 0.19% 0.18%

$536,039 $4,172,905 $1,184,144 $847,027 $6,275,029 $1,387,493 $730,908 $6,895,137 $0 $562,642

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$802,506 $6,752,285 $1,949,812 $1,293,238 $14,631,323 $3,329,338 $1,700,717 $28,803,843 $1 $2,107,044

$66,718 $561,363 $162,101 $107,516 $1,216,401 $276,790 $141,392 $2,394,658 $0 $175,173

$573 $4,822 $1,392 $923 $10,448 $2,377 $1,214 $20,568 $0 $1,505

$222.92 $312.61 $324.97 $269.42 $381.02 $396.35 $354.32 $489.86 #DIV/0! $438.97

$371.82 $505.80 $522.33 $445.89 $544.44 $561.53 $506.59 $607.13 #DIV/0! $556.18

$370.48 $504.48 $521.02 $444.55 $543.29 $560.40 $505.42 $606.15 #DIV/0! $555.18

5.39%

HMO - Off Exchange

86545CT131

0.00%

-0.06%

5.39%


Company Legal Name:

HIOS Issuer ID:




Product

Product ID:

Metal:

AV Metal Value

AV Pricing Value

Plan Type:

Plan Name


Exchange Plan?











Inpatient

Outpatient

Professional

Prescription Drug

Other

Capitation

Administration

Taxes & Fees


Total Rate Increase







Member Months

Total Premium (TP)



than EHB




than EHB





Net Amt of Rein

Net Amt of Risk Adj


Allowed Claims PMPM





Member Months

Total Premium (TP)



than EHB





than EHB








Net Amt of Rein

Net Amt of Risk Adj


Allowed Claims PMPM


Cla

ims

Info

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Pre

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m In

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atio

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Bronze Bronze Silver Silver Gold Bronze Bronze Silver Silver Silver Silver

0.612 0.615 0.711 0.714 0.810 0.603 0.590 0.707 0.713 0.681 0.681

0.774 0.702 1.022 1.037 1.232 0.712 0.674 0.979 1.003 0.905 0.882

PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

Bronze PPO

Standard Pathway

X

Bronze PPO

Standard Pathway

X for HSA

Silver PPO

Standard Pathway

X

Silver PPO

Pathway X

Gold PPO Standard

Pathway X

Anthem Bronze

PPO Century

Preferred

5700/11400/20%

Anthem Bronze

PPO Century

Preferred 6850/0%

Anthem Silver PPO

Century Preferred

2750/20%

Anthem Silver PPO

Century Preferred

2500/20%

Anthem Silver PPO

Century Preferred

3000/6000/20%

for HSA

Anthem Silver PPO

Century Preferred

3500/7000/10%

86545CT1330002 86545CT1330009 86545CT1330001 86545CT1330004 86545CT1330003 86545CT1340005 86545CT1340010 86545CT1340006 86545CT1340007 86545CT1340011 86545CT1340014

Yes Yes Yes Yes Yes No No No No No No

1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016

10.05% 3.64% 5.50% 6.83% 9.18% 11.10% 0.00% 7.57% 7.59% 0.00% 0.00%

10.05% 3.64% 5.50% 6.83% 9.18% 11.10% -999.00% 7.57% 7.59% -999.00% -999.00%

9.52% #DIV/0! 14.44% 15.54% 18.98% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


$4.69 -$0.25 -$1.47 $0.41 $0.70 $6.08 $0.00 $0.72 $0.21 $0.00 $0.00

$7.02 -$0.37 -$2.20 $0.62 $1.05 $9.09 $0.00 $1.07 $0.31 $0.00 $0.00

$6.67 -$0.35 -$2.09 $0.59 $1.00 $8.65 $0.00 $1.02 $0.30 $0.00 $0.00

$4.29 -$0.23 -$1.34 $0.38 $0.64 $5.56 $0.00 $0.66 $0.19 $0.00 $0.00

$0.67 -$0.04 -$0.21 $0.06 $0.10 $0.86 $0.00 $0.10 $0.03 $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

-$16.26 -$16.13 -$6.61 -$6.63 -$1.31 -$18.61 $0.00 -$8.76 -$8.00 $0.00 $0.00

$29.28 $29.67 $41.96 $41.63 $47.51 $26.46 $0.00 $38.78 $39.73 $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

$36.36 $12.31 $28.04 $37.06 $49.70 $38.09 $0.00 $33.59 $32.77 $0.00 $0.00

$1.41 -$15.32 -$16.89 -$15.65 -$15.33 -$25.02 $0.00 -$13.32 -$13.25 $0.00 $0.00

$361.87 $337.81 $509.73 $542.75 $541.43 $343.13 $0.00 $443.45 $431.78 $0.00 $0.00

20,400 13,200 165,600 54,000 66,000 42,000 4,800 8,400 4,800 12,000 4,800


$351.59 $0.00 $444.68 $446.69 $515.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

14,788 0 130,618 78,374 68,372 0 0 0 0 0 0

$5,199,357 $0 $58,082,586 $35,009,058 $35,251,665 $0 $0 $0 $0 $0 $0

99.69% 0.00% 99.75% 99.75% 99.79% 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%

0.31% 100.00% 0.25% 0.25% 0.21% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

$3,868,010 $0 $74,378,767 $49,436,243 $58,569,526 $0 $0 $0 $0 $0 $0

100.00% 0.00% 100.00% 100.00% 100.00% 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% 100.00% 0.00% 0.00% 0.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

$1,838,025 $0 $19,135,680 $10,103,064 $8,110,196 $0 $0 $0 $0 $0 $0

$3,892 $0 $10,117,894 $2,936,902 $0 $0 $0 $0 $0 $0 $0

0.21% #DIV/0! 52.87% 29.07% 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$2,029,985 $0 $55,243,087 $39,333,179 $50,459,330 $0 $0 $0 $0 $0 $0

-$485,898.70 $0.00 -$13,645,587.42 -$10,249,885.33 -$11,364,946.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$2,507,722.32 $0.00 -$9,163,919.50 -$4,686,700.15 -$14,505,254.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$137.27 #DIV/0! $422.94 $501.87 $738.01 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!




$385.08 $349.65 $508.90 $516.12 $613.44 $354.21 $335.65 $487.28 $499.26 $450.46 $438.94

20,400 13,200 165,600 54,000 66,000 42,000 4,800 8,400 4,800 12,000 4,800

$7,855,665 $4,615,356 $84,273,472 $27,870,650 $40,487,041 $14,876,631 $1,611,118 $4,093,149 $2,396,436 $5,405,579 $2,106,929

99.74% 99.71% 99.80% 99.81% 99.84% 99.72% 99.70% 99.79% 99.80% 99.78% 99.77%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.26% 0.29% 0.20% 0.19% 0.16% 0.28% 0.30% 0.21% 0.20% 0.22% 0.23%

$10,236,641 $5,975,203 $85,723,370 $30,618,842 $38,336,568 $19,600,557 $2,154,507 $4,759,300 $2,762,779 $6,391,774 $2,481,803

99.74% 99.71% 99.80% 99.81% 99.84% 99.72% 99.70% 99.79% 99.80% 99.78% 99.77%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.26% 0.29% 0.20% 0.19% 0.16% 0.28% 0.30% 0.21% 0.20% 0.22% 0.23%

$3,965,825 $2,291,617 $18,424,362 $8,361,053 $5,997,025 $7,727,131 $868,805 $1,490,735 $849,051 $2,075,679 $799,588

$0 $0 $11,371,307 $3,760,682 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 61.72% 44.98% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$6,270,816 $3,683,586 $67,299,008 $22,257,789 $32,339,543 $11,873,426 $1,285,702 $3,268,566 $1,913,728 $4,316,095 $1,682,215

$521,335 $306,241 $5,595,022 $1,850,441 $2,688,605 $987,118 $106,889 $271,738 $159,101 $358,826 $139,854

$4,478 $2,630 $48,055 $15,893 $23,092 $8,478 $918 $2,334 $1,367 $3,082 $1,201

$307.39 $279.06 $406.39 $412.18 $489.99 $282.70 $267.85 $389.11 $398.69 $359.67 $350.46

$501.80 $452.67 $517.65 $567.02 $580.86 $466.68 $448.86 $566.58 $575.58 $532.65 $517.04

$500.49 $451.35 $516.62 $565.94 $579.93 $465.37 $447.51 $565.39 $574.43 $531.48 $515.85

PPO

86545CT133

0.00%

0.62%

6.71%

6.71% 10.09%

PPO - Off Exchange

86545CT134

0.00%

-1.75%

10.09%


Company Legal Name:

HIOS Issuer ID:




Product

Product ID:

Metal:

AV Metal Value

AV Pricing Value

Plan Type:

Plan Name


Exchange Plan?











Inpatient

Outpatient

Professional

Prescription Drug

Other

Capitation

Administration

Taxes & Fees


Total Rate Increase







Member Months

Total Premium (TP)



than EHB




than EHB





Net Amt of Rein

Net Amt of Risk Adj


Allowed Claims PMPM





Member Months

Total Premium (TP)



than EHB





than EHB








Net Amt of Rein

Net Amt of Risk Adj


Allowed Claims PMPM


Cla

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Info

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HMO - MSP PPO - MSP

86545CT147 86545CT148

Silver Gold Gold Gold Gold Silver

0.712 0.780 0.817 0.806 0.792 0.714

0.898 1.166 1.243 1.148 1.072 1.036

PPO PPO PPO PPO HMO PPOAnthem Silver PPO

Century Preferred

Tiered

2850/4000/0%

Anthem Gold PPO

Century Preferred

1500/3000/20%

for HSA

Anthem Gold PPO

Century Preferred

1750/0%

Anthem Gold PPO

Century Preferred

Tiered

1750/3250/0%

Gold HMO

Pathway X

Enhanced, a Multi-

State Plan

Silver PPO

Pathway X, a Multi-

State Plan

86545CT1340015 86545CT1340012 86545CT1340013 86545CT1340016 86545CT1470002 86545CT1480002

No No No No Yes Yes

0.00% 0.00%

0.00% 0.00%

4.14% 6.81%

1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016

0.00% 0.00% 0.00% 0.00% 4.14% 6.82%

-999.00% -999.00% -999.00% -999.00% 4.14% 6.82%

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4.14% 6.81%

86545CT1340015 86545CT1340012 86545CT1340013 86545CT1340016 86545CT1470002 86545CT1480002

$0.00 $0.00 $0.00 $0.00 -$3.90 $0.16

$0.00 $0.00 $0.00 $0.00 -$5.84 $0.23

$0.00 $0.00 $0.00 $0.00 -$5.55 $0.22

$0.00 $0.00 $0.00 $0.00 -$3.57 $0.14

$0.00 $0.00 $0.00 $0.00 -$0.55 $0.02

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 -$4.51 -$6.67

$0.00 $0.00 $0.00 $0.00 $45.07 $41.58

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $21.14 $35.69

$0.00 $0.00 $0.00 $0.00 -$8.71 -$15.63

$0.00 $0.00 $0.00 $0.00 $510.24 $523.50

4,800 12,000 4,800 4,800 3,600 8,400

86545CT1340015 86545CT1340012 86545CT1340013 86545CT1340016 86545CT1470002 86545CT1480002

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00

0 0 0 0 0 0

$0 $0 $0 $0 $0 $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%

100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

$0 $0 $0 $0 $0 $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%

100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

$0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0 $0 $0 $0 $0 $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




86545CT1340015 86545CT1340012 86545CT1340013 86545CT1340016 86545CT1470002 86545CT1480002

$446.97 $580.39 $618.50 $571.37 $533.38 $515.51

4,800 12,000 4,800 4,800 3,600 8,400

$2,145,438 $6,964,634 $2,968,778 $2,742,562 $1,920,176 $4,330,263

99.78% 99.83% 99.84% 99.82% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.22% 0.17% 0.16% 0.18% 0.00% 0.00%

$2,438,255 $7,487,698 $2,912,188 $2,742,888 $1,940,017 $4,757,241

99.78% 99.83% 99.84% 99.82% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.22% 0.17% 0.16% 0.18% 0.00% 0.00%

$725,247 $1,924,814 $540,766 $552,369 $406,509 $1,299,055

$0 $0 $0 $0 $0 $584,297

0.00% 0.00% 0.00% 0.00% 0.00% 44.98%

$1,713,008 $5,562,884 $2,371,423 $2,190,519 $1,533,508 $3,458,187

$142,414 $462,480 $197,152 $182,113 $127,491 $287,502

$1,223 $3,972 $1,693 $1,564 $1,095 $2,469

$356.88 $463.57 $494.05 $456.36 $425.97 $411.69

$507.97 $623.97 $606.71 $571.44 $538.89 $566.34

$506.85 $622.91 $605.74 $570.41 $538.89 $566.34

10.09%

PPO - Off Exchange

86545CT134

0.00%

-1.75%

10.09%

2016 Individual Standard GoldUser Inputs for Plan Parameters

Use Integrated Medical and Drug Deductible?

Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?

Apply Skilled Nursing Facility Copay per Day? 100%

Use Separate OOP Maximum for Medical and Drug Spending? 0%

Indicate if Plan Meets CSR Standard?

Desired Metal Tier

Medical Drug Combined Medical Drug Combined

Deductible ($) $1,000.00 $25.00

Coinsurance (%, Insurer's Cost Share) 100.00% 80.00%

OOP Maximum ($)

OOP Maximum if Separate ($)

Click Here for Important Instructions Tier 1 Tier 2

Type of BenefitSubject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical

Emergency Room Services $100.00

All Inpatient Hospital Services (inc. MHSA) $500.00

Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and

X-rays)$20.00

Specialist Visit $40.00

Mental/Behavioral Health and Substance Abuse Disorder

Outpatient Services$48.80

Imaging (CT/PET Scans, MRIs) $65.00

Rehabilitative Speech Therapy $20.00

Rehabilitative Occupational and Rehabilitative Physical Therapy$20.00

Preventive Care/Screening/Immunization 100% $0.00 100% $0.00

Laboratory Outpatient and Professional Services $25.00

X-rays and Diagnostic Imaging $40.00

Skilled Nursing Facility $500.00

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) 80%

Outpatient Surgery Physician/Surgical Services 80%

Drugs

Generics $5.00

Preferred Brand Drugs $25.00

Non-Preferred Brand Drugs $50.00

Specialty Drugs (i.e. high-cost)

Options for Additional Benefit Design Limits:

Set a Maximum on Specialty Rx Coinsurance Payments?

Specialty Rx Coinsurance Maximum: $100

Set a Maximum Number of Days for Charging an IP Copay?

# Days (1-10): 2

Begin Primary Care Cost-Sharing After a Set Number of Visits?

# Visits (1-10):

Begin Primary Care Deductible/Coinsurance After a Set Number of

Copays?

# Copays (1-10):

Output

Status/Error Messages: Calculation Successful.

Actuarial Value: 81.04%

Metal Tier: Gold

Copay applies only after

deductible?

HSA/HRA Options Narrow Network Options

Annual Contribution Amount: $0.002nd Tier Utilization:

1st Tier Utilization:

Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design

Tier 1 Tier 2

$3,000.00

Calculate

All

All

All

All

All

All

All

All

All All

All All

Appendix D-2

HIOS Issuer ID: 86545HIOS Product ID: 86545CT133HIOS Plan ID: 86545CT1330003

Provided by Wakely Consulting

2016 Individual Standard SilverUser Inputs for Plan Parameters






Desired Metal Tier


Deductible ($) $2,900.00 $150.00


OOP Maximum ($)




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




X-rays)$30.00













Drugs

Generics $5.00








# Days (1-10): 4


# Visits (1-10):


Copays?

# Copays (1-10):

Output



Metal Tier: Silver


deductible?





Tier 1 Tier 2

$6,850.00

Calculate

All

All

All

All

All

All

All

All

All All

All All

Appendix D-3



2016 Individual Standard Silver - 94% CSRUser Inputs for Plan Parameters






Desired Metal Tier


Deductible ($) $0.00 $0.00


OOP Maximum ($)




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




X-rays)$10.00













Drugs

Generics $5.00








# Days (1-10): 4


# Visits (1-10):


Copays?

# Copays (1-10):

Output

Status/Error Messages: CSR Level of 94% (100-150% FPL), Calculation Successful.


Metal Tier: Platinum


deductible?





Tier 1 Tier 2

$800.00

Calculate

All

All

All

All

All

All

All

All

All All

All All

Appendix D-4









Desired Metal Tier


Deductible ($) $500.00 $50.00


OOP Maximum ($)




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




X-rays)$20.00













Drugs

Generics $5.00








# Days (1-10): 4


# Visits (1-10):


Copays?

# Copays (1-10):

Output



Metal Tier: Gold


deductible?





Tier 1 Tier 2

$1,800.00

Calculate

All

All

All

All

All

All

All

All

All All

All All

Appendix D-5









Desired Metal Tier


Deductible ($) $2,200.00 $100.00


OOP Maximum ($)




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




X-rays)$30.00













Drugs

Generics $5.00








# Days (1-10): 4


# Visits (1-10):


Copays?

# Copays (1-10):

Output



Metal Tier: Silver


deductible?





Tier 1 Tier 2

$5,200.00

Calculate

All

All

All

All

All

All

All

All

All All

All All

Appendix D-6



2016 Individual & SHOP Standard BronzeUser Inputs for Plan Parameters






Desired Metal Tier


Deductible ($) $5,500.00

Coinsurance (%, Insurer's Cost Share) 50.00%

OOP Maximum ($) $6,850.00




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




X-rays)$40.00













Drugs

Generics $5.00

Preferred Brand Drugs 50%

Non-Preferred Brand Drugs 50%

Specialty Drugs (i.e. high-cost) 50%





# Days (1-10): 4


# Visits (1-10):


Copays?

# Copays (1-10):

Output



Metal Tier: Bronze


deductible?





Tier 1 Tier 2

Calculate

All

All

All

All

All

All

All

All

All All

All All

Appendix D-7



2016 Standard Individual & SHOP Bronze HSA - UnadjustedUser Inputs for Plan Parameters






Desired Metal Tier








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical

Emergency Room Services

All Inpatient Hospital Services (inc. MHSA)


X-rays)

Specialist Visit


Outpatient Services

Imaging (CT/PET Scans, MRIs)

Rehabilitative Speech Therapy

Rehabilitative Occupational and Rehabilitative Physical Therapy


Laboratory Outpatient and Professional Services

X-rays and Diagnostic Imaging

Skilled Nursing Facility

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Outpatient Surgery Physician/Surgical Services

Drugs

Generics








# Days (1-10):


# Visits (1-10):


Copays?

# Copays (1-10):

Output



Metal Tier: Bronze


deductible?





Tier 1 Tier 2

Calculate

All

All

All

All

All

All

All

All

All All

All All

Appendix D-8




HIOS Product ID: 86545CT123

HIOS Plan ID: 86545CT1230001

User Inputs for Plan Parameters



Apply Skilled Nursing Facility Copay per Day?

Use Separate OOP Maximum for Medical and Drug Spending?


Desired Metal Tier Bronze








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical



Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays)

Specialist Visit

Mental/Behavioral Health and Substance Abuse Disorder Outpatient

Services




Preventive Care/Screening/Immunization 100% $0.00






Drugs

Generics

Preferred Brand Drugs

Non-Preferred Brand Drugs




Specialty Rx Coinsurance Maximum:


# Days (1-10):


# Visits (1-10):

Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?

# Copays (1-10):

Output



Metal Tier: Bronze

$3,403.31

$5,598.79


Annual Contribution Amount:1st Tier Utilization:

2nd Tier Utilization:

Copay applies only after deductible?


Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical



Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) 76%

Specialist Visit


Services69%

Imaging (CT/PET Scans, MRIs) 91%









Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Bronze

$3,412.10

$5,598.79






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All










Desired Metal Tier Silver








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services89%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,150.21

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All



HIOS Plan ID: 86545CT1330004-04















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services92%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,276.17

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All



HIOS Plan ID: 86545CT1330004-05







Desired Metal Tier Gold








Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services95%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$5,307.48

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All



HIOS Plan ID: 86545CT1330004-06







Desired Metal Tier Platinum


Deductible ($) $300.00


OOP Maximum ($) $600.00




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services96%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output




$6,167.34

$6,543.47






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services89%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,150.21

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All



HIOS Plan ID: 86545CT1480002-04















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services92%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,282.06

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All



HIOS Plan ID: 86545CT1480002-05















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services95%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$5,307.48

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All



HIOS Plan ID: 86545CT1480002-06







Desired Metal Tier Platinum


Deductible ($) $300.00


OOP Maximum ($) $600.00




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services96%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output




$6,167.34

$6,543.47






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical



Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) $30.00



Services79%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$4,948.38

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services79%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$4,820.33

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Bronze

$3,428.65

$5,598.79






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services71%










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Bronze

$3,374.36

$5,598.79






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Bronze

$3,378.12

$5,598.79






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,098.79

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services52%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,163.75

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services74%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,108.41

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services79%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$4,948.38

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services70%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,139.80

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services79%










Drugs

Generics $5.00








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$4,820.33

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Bronze

$3,355.88

$5,598.79






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Bronze

$3,304.62

$5,598.79






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$3,955.74

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$4,751.73

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services66%



Rehabilitative Occupational and Rehabilitative Physical Therapy $30.00


Laboratory Outpatient and Professional Services 28%

X-rays and Diagnostic Imaging 84%




Drugs

Generics $5.00



Specialty Drugs (i.e. high-cost) $60.00





# Days (1-10): 2


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$4,975.92

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All


















Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical




Specialist Visit


Services










Drugs

Generics








# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$3,957.92

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All












Deductible ($) $3,000.00 $3,850.00


OOP Maximum ($) $6,850.00 $6,850.00




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical

Emergency Room Services $200.00 $200.00

All Inpatient Hospital Services (inc. MHSA) $400.00 $500.00

Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) $30.00 $40.00

Specialist Visit $50.00 $50.00


Services79% 72%

Imaging (CT/PET Scans, MRIs) 91% 91%

Rehabilitative Speech Therapy $40.00 $40.00

Rehabilitative Occupational and Rehabilitative Physical Therapy $40.00 $40.00


Laboratory Outpatient and Professional Services 25% 25%

X-rays and Diagnostic Imaging 88% 88%

Skilled Nursing Facility $400.00 $500.00



Drugs

Generics $5.00 $5.00

Preferred Brand Drugs $60.00 $60.00

Non-Preferred Brand Drugs 50% 50%

Specialty Drugs (i.e. high-cost) 50% 50%





# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,117.13

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All












Deductible ($) $2,850.00 $4,000.00


OOP Maximum ($) $6,850.00 $6,850.00




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services79% 72%

Imaging (CT/PET Scans, MRIs) 91% 91%

Rehabilitative Speech Therapy $40.00 $40.00

Rehabilitative Occupational and Rehabilitative Physical Therapy $40.00 $40.00


Laboratory Outpatient and Professional Services 25% 25%

X-rays and Diagnostic Imaging 88% 88%




Drugs



Non-Preferred Brand Drugs 50% 50%

Specialty Drugs (i.e. high-cost) 50% 50%





# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Silver

$4,135.48

$5,809.58






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All












Deductible ($) $1,750.00 $3,250.00


OOP Maximum ($) $6,850.00 $6,850.00




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services86% 72%










Drugs









# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$4,905.98

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All












Deductible ($) $2,000.00 $3,500.00


OOP Maximum ($) $6,850.00 $6,850.00




Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Subject to

Deductible?

Subject to

Coinsurance?

Coinsurance, if

different

Copay, if

separate

Medical






Services86% 72%










Drugs









# Days (1-10):


# Visits (1-10):


# Copays (1-10):

Output



Metal Tier: Gold

$4,835.31

$6,088.36






Tier 1 Tier 2

All

All

All

All

All

All

All

All

All All

All All

Please fill in the following information.

HIOS Issuer ID:

HIOS Product IDs:

Applicable HIOS Plan IDs (Standard Component):

86545CT1230002

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

the AV calculator and the materiality of those benefits):

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3

86545

86545CT123

Benefit designs include one or more of the following benefit features not supported by the functionality of the AV calculator:

A. Flat dollar copayment for Outpatient Facility Fee

B. Flat dollar copayment for Outpatient Surgery Physician/Surgical Services

C. Flat dollar copayment and percentage coinsurance for the same medical or Rx benefit category

Benefit designs have member cost shares that differ by site of service for Outpatient Mental/Behavioral Health and Substance Use Disorders

(MH), specifically outpatient MH office visits versus other outpatient MH facility and professional visits. The AV calculator does not have the

functionality to vary cost shares by site of service.

Benefit designs apply a member copay prior to deductible for a limited number of office visits with remaining office visits subject to deductible

and coinsurance. The limited visits at a copayment are combined across multiple benefit categories. In addition to Primary Care Visit, limits apply

across Outpatient Mental/Behavioral Health and Substance Use Disorder Office Services, Rehabilitative Speech Therapy, and/or Rehabilitative

Physical and Occupational Therapies. The limited copays prior to deductible functionality in the AV calculator is only applicable to the Primary

Care Visit benefit category.

Unique Plan Design Supporting

Documentation and Justification

Version 1 Page 1 of 4

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

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3

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

considered: Yes

Description of the standardized plan population data used: Used AV Calculator population data.

Per 156.135(b)(2), A weighted average of the member cost shares for outpatient professional mental health office visits and the member cost shares

for outpatient mental health facility and professional other visits was converted to effective coinsurance rates

Per 156.135(b)(2), A weighted average was applied to the office visit services subject to the limited copayments combined with the remainder of

the visits subject to plan deductible and coinsurance, then converted to an effective coinsurance.

Per 156.135(b)(2), The actual cost shares were converted into effective coinsurance rates.


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:

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3

For Outpatient Facility Fee, used the average cost and frequency data from a nationally recognized consulting firm trended to 2016. For all other

benefit categories, used the cost and frequency data from the AV calculator continuance tables at the appropriate charge level associated with the

OOP limit. Used linear interpolation when the exact level was not available in the continuance table. The charge level associated with the OOP

was considered "unlimited" when the plan overall (medical or Rx, as applicable) coinsurance was 100%. When the plan overall coinsurance was

less than 100%, the following formula was used to calculate the charge level associated with the OOP.

(OOP Max - Deductible)

Stop Loss = ――――――――――― + Deductible

1 - Plan Coinsurance

where Stop Loss = charge level associated with OOP

The effective coinsurance was calculated using the following formula:

(Ben Cost - Ben Copay • Ben Freq) x (1-Ben Coins)

Plan Eff Coins = Min( 1, Max( 0, ――――――――――――――――――――――― ))

Ben Cost

where:

Ben Cost = average benefit cost PMPY

Ben Freq = average benefit frequency PMPY

Ben Copay = member copayment for the benefit category

Ben Coins = member coinsurance for the benefit category

The Interim Final Rule 45 CFR Part 146 under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008

(MHP) and EHB guidance allows separation of cost share types between outpatient other and office visits as allowed under the MHPAEA July 1,

2010 Enforcement Safe Harbor guidance. The Final Rule released on November 13, 2013 retained the subclassification provision. These benefit

designs have been tested and meet the regulatory requirements. Using proprietary claims data, from a nationally known consulting firm,

frequency weightings calculated and applied to the member cost shares for MH/SA services in an office based setting and member cost shares in a

hospital or facility setting. The results were combined to calculate an effective coinsurance used in the AV calculation.

Using Proprietary claims data, weightings were determined to model the number of office visit services that would be subject to a limited

copayment or the plan deductible and coinsurance. Due to the combined structure of the office visit services, across several categories, a

redistribution of the weighting factors were modeled based on frequency of service statistics from a nationally known consulting firm. The final

weightings were used to convert the plan member cost shares to an effective coinsurance for each service category subject to the limited visits at a

copayment.


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

used to develop the adjustments: This method was not used.

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;

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

Actuary signature:

Actuary Printed Name:Michele L. Archer, FSA, MAAA

Date: April 27, 2015



HIOS Issuer ID:

HIOS Product IDs:


86545CT1330004, 86545CT1480002



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2

86545

86545CT133, 86545CT148













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2


considered: Yes









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copayment.
