table of contents for individual on and off exchange...mvp health plan, inc. effective january 1,...

MVP Health Plan, Inc.Effective January 1, 2018

Table of Contentsfor

Individual On and Off Exchange

Exhibit A Benefit Descriptions 1Exhibit A.1 Rider Descriptions 25Exhibit B HIOS Plan ID to Forms 26Exhibit C Premiums 42Exhibit D Premiums by HIOS Plan ID 98Exhibit E Example of Premium Calculation with Rider 129

Exhibit FAdjustment Factors For Major Variations From The Base Plan 130

Exhibit G Area Factor 131Exhibit H Standard Census Tiers and Factors 133Exhibit I Underwriting Guidelines 134Exhibit J Commission Schedule 136

MVP Health Plan, Inc. Exhibit ABenefit DescriptionsEffective January 1, 2018Version 8/16/2017

MVP Form ID Form Description Plan TypeSmall vs Individual

Standard vs Non-Standard Metal Level

Form Applies to: On vs Off

Exchange

Availble to "Child

Only" Marketing Name

FRNY-HMOH-DB-001-S (2018) Standard Bronze QHDHP HMO Individual Standard Bronze On Yes MVP PremierFRNY-HMOH-DBA1-001-S (2018) Standard Bronze AI/NA Variation QHDHP HMO Individual Standard Bronze On Yes MVP Premier

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 HMO Individual Standard Bronze On Yes MVP PremierFRNY-HMO-DBA1-002-S (2018) Standard Bronze 2 AI/NA Variation HMO Individual Standard Bronze On Yes MVP Premier

FRNY-HMO-DS-001-S (2018) Standard Silver HMO Individual Standard Silver On Yes MVP PremierFRNY-HMO-DSA1-001-S (2018) Standard Silver AI/NA Variation HMO Individual Standard Silver On Yes MVP PremierFRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 HMO Individual Standard Silver On Yes MVP PremierFRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 HMO Individual Standard Silver On Yes MVP PremierFRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 HMO Individual Standard Silver On Yes MVP Premier

FRNY-HMO-DS-002-S (2018) Standard Silver 2 HMO Individual Standard Silver On Yes MVP PremierFRNY-HMO-DSA1-002-S (2018) Standard Silver 2 AI/NA Variation HMO Individual Standard Silver On Yes MVP Premier

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 HMO Individual Standard Silver On Yes MVP Premier

Page 1





Exchange

Availble to "Child




FRNY-HMO-DG-001-S (2018) Standard Gold HMO Individual Standard Gold On Yes MVP PremierFRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation HMO Individual Standard Gold On Yes MVP Premier

FRNY-HMO-DG-002-S (2018) Standard Gold 2 HMO Individual Standard Gold On Yes MVP PremierFRNY-HMO-DGA1-002-S (2018) Standard Gold 2 AI/NA Variation HMO Individual Standard Gold On Yes MVP Premier

FRNY-HMO-DP-001-S (2018) Standard Platinum HMO Individual Standard Platinum On Yes MVP PremierFRNY-HMO-DPA1-001-S (2018) Standard Platinum AI/NA Variation HMO Individual Standard Platinum On Yes MVP Premier

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 HMO Individual Non-Standard Bronze On No MVP Premier PlusFRNY-HMO-DBA1-001-N (2018) Non-Standard Bronze 1 AI/NA Variation HMO Individual Non-Standard Bronze On No MVP Premier Plus

Page 2





Exchange

Availble to "Child


FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 HMO Individual Non-Standard Bronze On No MVP Premier PlusFRNY-HMO-DBA1-002-N (2018) Non-Standard Bronze 2 AI/NA Variation HMO Individual Non-Standard Bronze On No MVP Premier Plus

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 QHDHP HMO Individual Non-Standard Bronze On No MVP Premier Plus HDHPFRNY-HMOH-DBA1-003-N (2018) Non-Standard Bronze 3 AI/NA Variation QHDHP HMO Individual Non-Standard Bronze On No MVP Premier Plus HDHP

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 HMO Individual Non-Standard Silver On No MVP Premier PlusFRNY-HMO-DSA1-001-N (2018) Non-Standard Silver 1 AI/NA Variation HMO Individual Non-Standard Silver On No MVP Premier PlusFRNY-HMO-DS1-001-N-73 (2018) Non-Standard Silver 1 CSR AV73 HMO Individual Non-Standard Silver On No MVP Premier PlusFRNY-HMO-DS1-001-N-87 (2018) Non-Standard Silver 1 CSR AV87 HMO Individual Non-Standard Silver On No MVP Premier PlusFRNY-HMO-DS1-001-N-94 (2018) Non-Standard Silver 1 CSR AV94 HMO Individual Non-Standard Silver On No MVP Premier Plus

FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 HMO Individual Non-Standard Silver On No MVP Premier PlusFRNY-HMO-DSA1-002-N (2018) Non-Standard Silver 2 AI/NA Variation HMO Individual Non-Standard Silver On No MVP Premier Plus

FRNY-HMO-DS1-002-N-73 (2018) Non-Standard Silver 2 CSR AV73 HMO Individual Non-Standard Silver On No MVP Premier Plus


Page 3





Exchange

Availble to "Child



FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 QHDHP HMO Individual Non-Standard Silver On No MVP Premier Plus HDHPFRNY-HMOH-DSA1-003-N (2018) Non-Standard Silver 3 AI/NA Variation QHDHP HMO Individual Non-Standard Silver On No MVP Premier Plus HDHPFRNY-HMOH-DS1-003-N-73 (2018) Non-Standard Silver 3 CSR AV73 QHDHP HMO Individual Non-Standard Silver On No MVP Premier Plus HDHP

FRNY-HMOH-DS1-003-N-87 (2018) Non-Standard Silver 3 CSR AV87QHDHP HMO (Agg) Individual Non-Standard Silver On No MVP Premier Plus HDHP

FRNY-HMOH-DS1-003-N-94 (2018) Non-Standard Silver 3 CSR AV94QHDHP HMO (Agg) Individual Non-Standard Silver On No MVP Premier Plus HDHP

FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 HMO Individual Non-Standard Gold On No MVP Premier PlusFRNY-HMO-DGA1-001-N (2018) Non-Standard Gold 1 AI/NA Variation HMO Individual Non-Standard Gold On No MVP Premier Plus

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 QHDHP HMO Individual Non-Standard Gold On No MVP Premier Plus HDHPFRNY-HMOH-DGA1-002-N (2018) Non-Standard Gold 2 AI/NA Variation QHDHP HMO Individual Non-Standard Gold On No MVP Premier Plus HDHP

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 HMO Individual Non-Standard Platinum On No MVP Premier PlusFRNY-HMO-DPA1-001-N (2018) Non-Standard Platinum 1 AI/NA Variation HMO Individual Non-Standard Platinum On No MVP Premier Plus

Page 4





Exchange

Availble to "Child


FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 HMO Individual Non-Standard Platinum On No MVP Premier PlusFRNY-HMO-DPA1-002-N (2018) Non-Standard Platinum 2 AI/NA Variation HMO Individual Non-Standard Platinum On No MVP Premier Plus

FRNY-HMO-DC-001-S (2018) Catastrophic HMO Individual Standard Catastrophic On No MVP SecureFRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National QHDHP HMO Individual Non-Standard Gold On No MVP Premier PlusFRNY-HMOH-DGA1-001-NN (2018) Non-Standard Gold 1 National AI/NA Variation QHDHP HMO Individual Non-Standard Gold On No MVP Premier PlusFRNY-HMO-DP-001-NN (2018) Non-Standard Platinum 1 National HMO Individual Non-Standard Platinum On No MVP Premier PlusFRNY-HMO-DPA1-001-NN (2018) Non-Standard Platinum 1 National AI/NA Variat HMO Individual Non-Standard Platinum On No MVP Premier PlusNY-HMOH-DB-001-S (2018) Standard Bronze QHDHP HMO Individual Standard Bronze Off No MVP PremierNY-HMO-DB-002-S (2018) Standard Bronze 2 HMO Individual Standard Bronze Off No MVP PremierNY-HMO-DS-001-S (2018) Standard Silver HMO Individual Standard Silver Off No MVP Premier

NY-HMO-DS-002-S (2018) Standard Silver 2 HMO Individual Standard Silver Off No MVP PremierNY-HMO-DG-001-S (2018) Standard Gold HMO Individual Standard Gold Off No MVP Premier

NY-HMO-DG-002-S (2018) Standard Gold 2 HMO Individual Standard Gold Off No MVP PremierNY-HMO-DP-001-S (2018) Standard Platinum HMO Individual Standard Platinum Off No MVP PremierNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 HMO Individual Non-Standard Bronze Off No MVP Premier Plus

NY-HMO-DB-002-N (2018) Non-Standard Bronze 2 HMO Individual Non-Standard Bronze Off No MVP Premier PlusNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 QHDHP HMO Individual Non-Standard Bronze Off No MVP Premier Plus HDHPNY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 QHDHP HMO Individual Non-Standard Bronze Off No MVP Premier Plus HDHP

NY-HMO-DB-008-N (2018) Non-Standard Bronze 8 HMO Individual Non-Standard Bronze Off No MVP Premier PlusNY-HMO-DS-001-N (2018) Non-Standard Silver 1 HMO Individual Non-Standard Silver Off No MVP Premier Plus

NY-HMO-DS-002-N (2018) Non-Standard Silver 2 HMO Individual Non-Standard Silver Off No MVP Premier PlusNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 QHDHP HMO Individual Non-Standard Silver Off No MVP Premier Plus HDHPNY-HMO-DS-010-N (2018) Non-Standard Silver 10 HMO Individual Non-Standard Silver Off No MVP Premier Plus

NY-HMO-DG-001-N (2018) Non-Standard Gold 1 HMO Individual Non-Standard Gold Off No MVP Premier PlusNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 QHDHP HMO Individual Non-Standard Gold Off No MVP Premier Plus HDHPNY-HMO-DG-004-N (2018) Non-Standard Gold 4 HMO Individual Non-Standard Gold Off No MVP Premier Plus

Page 5





Exchange

Availble to "Child

Only" Marketing NameNY-HMO-DG-005-N (2018) Non-Standard Gold 5 HMO Individual Non-Standard Gold Off No MVP Premier PlusNY-HMO-DG-008-N (2018) Non-Standard Gold 8 HMO Individual Non-Standard Gold Off No MVP Premier PlusNY-HMO-DG-009-N (2018) Non-Standard Gold 9 HMO Individual Non-Standard Gold Off No MVP Premier Plus

NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 HMO Individual Non-Standard Platinum Off No MVP Premier PlusNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 HMO Individual Non-Standard Platinum Off No MVP Premier PlusNY-HMOH-DB-001-NN (2018) Non-Standard Bronze 1 National QHDHP HMO Individual Non-Standard Bronze Off No MVP Premier Plus HDHPNY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National QHDHP HMO Individual Non-Standard Silver Off No MVP Premier Plus HDHPNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National QHDHP HMO Individual Non-Standard Gold Off No MVP Premier PlusNY-HMO-DP-001-NN (2018) Non-Standard Platinum 1 National HMO Individual Non-Standard Platinum Off No MVP Premier PlusNY-POS-DP-001-S (2018) CompCare POS Replacement POS Individual Standard Platinum Off No MVP Premier

NY-HMO-DC-001-S (2018) Catastrophic HMO Individual Standard Catastrophic Off No MVP SecureNY-HMOH-DB-001-S-CO (2018) Standard Bronze QHDHP HMO Individual Standard Bronze Off Yes MVP PremierNY-HMO-DB-002-S-CO (2018) Standard Bronze 2 HMO Individual Standard Bronze Off Yes MVP PremierNY-HMO-DS-001-S-CO (2018) Standard Silver HMO Individual Standard Silver Off Yes MVP Premier

NY-HMO-DS-002-S-CO (2018) Standard Silver 2 HMO Individual Standard Silver Off Yes MVP PremierNY-HMO-DG-001-S-CO (2018) Standard Gold HMO Individual Standard Gold Off Yes MVP Premier

NY-HMO-DG-002-S-CO (2018) Standard Gold 2 HMO Individual Standard Gold Off Yes MVP PremierNY-HMO-DP-001-S-CO (2018) Standard Platinum HMO Individual Standard Platinum Off Yes MVP Premier

NOTE:All cost sharing after Deductible unless otherwise noted by "no DD"Benefit summaries are illustrative only. See schedule for benefits.

Page 6

MVP Health Plan, Inc.Benefit DescriptionsEffective January 1, 2018Version 8/16/2017

MVP Form ID

FRNY-HMOH-DB-001-S (2018)FRNY-HMOH-DBA1-001-S (2018)

FRNY-HMO-DB-002-S (2018)FRNY-HMO-DBA1-002-S (2018)

FRNY-HMO-DS-001-S (2018)FRNY-HMO-DSA1-001-S (2018)FRNY-HMO-DS1-001-S-73 (2018)FRNY-HMO-DS1-001-S-87 (2018)FRNY-HMO-DS1-001-S-94 (2018)

FRNY-HMO-DS-002-S (2018)FRNY-HMO-DSA1-002-S (2018)

FRNY-HMO-DS1-002-S-73 (2018)

Exhibit A

Deductible Type

Single Deductible

Medical

Family Deductible

MedicalOOP Max

TypeSingle OOP Maximum

Family OOP Maximum

Emergency Room

Inpatient Stay/SNF

Outpatient Facility Primary Care Office

Specialist Office

Embedded $5,500 $11,000 Embedded $6,550 $13,100 50% 50% 50% 50% 50%N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Embedded $4,000 $8,000 Embedded $7,150 $14,300 50% 50% 50% 50% 50%N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Embedded $2,000 $4,000 Embedded $6,750 $13,500 $250 $1,500 $100 $30 $50N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0Embedded $1,650 $3,300 Embedded $5,550 $11,100 $250 $1,500 $100 $30 $50Embedded $250 $500 Embedded $2,100 $4,200 $75 $250 $75 $15 $35Embedded $0 $0 Embedded $1,000 $2,000 $50 $100 $25 $10 $20

Embedded $2,350 $4,700 Embedded $7,150 $14,300 $250 $1,500 $1003 visits at $35 No DD,

then $35 after DD $55N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0


then $35 after DD $55

Page 7


MVP Form ID

FRNY-HMO-DS1-002-S-87 (2018)

FRNY-HMO-DS1-002-S-94 (2018)

FRNY-HMO-DG-001-S (2018)FRNY-HMO-DGA1-001-S (2018)


FRNY-HMO-DP-001-S (2018)FRNY-HMO-DPA1-001-S (2018)

FRNY-HMO-DB-001-N (2018)FRNY-HMO-DBA1-001-N (2018)

Exhibit A

Deductible Type

Single Deductible

Medical

Family Deductible

MedicalOOP Max


Family OOP Maximum

Emergency Room

Inpatient Stay/SNF


Specialist Office

Embedded $400 $800 Embedded $2,000 $4,000 $75 $250 $753 visits at $15 No DD,


Embedded $0 $0 Embedded $1,000 $2,000 $50 $100 $253 visits at $10 No DD,


Embedded $600 $1,200 Embedded $4,000 $8,000 $150 $1,000 $100 $25 $40N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Embedded $650 $1,300 Embedded $5,000 $10,000 $150 $1,000 $1003 visits at $25 No DD,

thern $25 DD $40N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

N/A $0 $0 Embedded $2,000 $4,000 $100 $500 $100 $15 $35N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Embedded $4,500 $9,000 Embedded $7,350 $14,700 $500 $1,500 $300 $40 $80N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Page 8


MVP Form ID


FRNY-HMOH-DB-003-N (2018)FRNY-HMOH-DBA1-003-N (2018)

FRNY-HMO-DS-001-N (2018)FRNY-HMO-DSA1-001-N (2018)FRNY-HMO-DS1-001-N-73 (2018)FRNY-HMO-DS1-001-N-87 (2018)FRNY-HMO-DS1-001-N-94 (2018)

FRNY-HMO-DS-002-N (2018)FRNY-HMO-DSA1-002-N (2018)

FRNY-HMO-DS1-002-N-73 (2018)

FRNY-HMO-DS1-002-N-87 (2018)

Exhibit A

Deductible Type

Single Deductible

Medical

Family Deductible

MedicalOOP Max


Family OOP Maximum

Emergency Room

Inpatient Stay/SNF


Specialist Office

Embedded $5,100 $10,200 Embedded $7,150 $14,300 40% 40% 40%3 visit at $0 No DD, then

40% after DD 40%N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Embedded $5,900 $11,800 Embedded $6,550 $13,100 $500 30% $100 $30 $50N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Embedded $1,800 $3,600 Embedded $6,800 $13,600 $500 20% $300 $40 no DD $60N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0Embedded $1,250 $2,500 Embedded $5,700 $11,400 $275 20% $300 $30 no DD $50Embedded $500 $1,000 Embedded $2,350 $4,700 $75 20% $100 $5 no DD $25Embedded $100 $200 Embedded $700 $1,400 $75 20% $75 $5 no DD $15

Embedded $3,400 $6,800 Embedded $6,350 $12,700 $500 no DD 20% $2003 visits at $0 No DD,

then $40 no DD $70N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0


then $40 no DD $70

Embedded $350 $700 Embedded $2,100 $4,200 $200 no DD 20% $1003 visits at $0 No DD,

then $5 no DD $25

Page 9


MVP Form ID

FRNY-HMO-DS1-002-N-94 (2018)

FRNY-HMOH-DS-003-N (2018)FRNY-HMOH-DSA1-003-N (2018)FRNY-HMOH-DS1-003-N-73 (2018)

FRNY-HMOH-DS1-003-N-87 (2018)

FRNY-HMOH-DS1-003-N-94 (2018)

FRNY-HMO-DG-001-N (2018)FRNY-HMO-DGA1-001-N (2018)

FRNY-HMOH-DG-002-N (2018)FRNY-HMOH-DGA1-002-N (2018)

FRNY-HMO-DP-001-N (2018)FRNY-HMO-DPA1-001-N (2018)

Exhibit A

Deductible Type

Single Deductible

Medical

Family Deductible

MedicalOOP Max


Family OOP Maximum

Emergency Room

Inpatient Stay/SNF


Specialist Office

Embedded $50 $100 Embedded $1,300 $2,600 $150 no DD 20% $503 visits at $0 No DD,

then $5 no DD $15

Aggregate $2,500 $5,000 Embedded $5,000 $10,000 $300 $500 $200 $30 $60N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0Aggregate $1,700 $3,400 Embedded $4,500 $9,000 $200 $500 $200 $25 $50

Aggregate $400 $800 Embedded $2,000 $4,000 $100 $300 $100 $5 $15

Aggregate $200 $400 Embedded $800 $1,600 $50 $100 $50 $5 $5

Embedded $950 $1,900 Embedded $5,500 $11,000 $350 no DD $500 $2003 visits at $0 No DD,

then $15 No DD $50N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Aggregate $1,350 $2,700 Embedded $4,100 $8,200 $75 $400 $100 $5 $25N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

N/A $0 $0 Embedded $2,200 $4,400 $200 $300 $1003 visits at $0 No DD,

then $10 after DD $45N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Page 10


MVP Form ID


FRNY-HMO-DC-001-S (2018)FRNY-HMOH-DG-001-NN (2018)FRNY-HMOH-DGA1-001-NN (2018)FRNY-HMO-DP-001-NN (2018)FRNY-HMO-DPA1-001-NN (2018)NY-HMOH-DB-001-S (2018)NY-HMO-DB-002-S (2018)NY-HMO-DS-001-S (2018)

NY-HMO-DS-002-S (2018)NY-HMO-DG-001-S (2018)

NY-HMO-DG-002-S (2018)NY-HMO-DP-001-S (2018)NY-HMO-DB-001-N (2018)

NY-HMO-DB-002-N (2018)NY-HMOH-DB-003-N (2018)NY-HMOH-DB-006-N (2018)

NY-HMO-DB-008-N (2018)NY-HMO-DS-001-N (2018)

NY-HMO-DS-002-N (2018)NY-HMOH-DS-003-N (2018)NY-HMO-DS-010-N (2018)

NY-HMO-DG-001-N (2018)NY-HMOH-DG-002-N (2018)NY-HMO-DG-004-N (2018)

Exhibit A

Deductible Type

Single Deductible

Medical

Family Deductible

MedicalOOP Max


Family OOP Maximum

Emergency Room

Inpatient Stay/SNF


Specialist Office

N/A $0 $0 Embedded $2,400 $4,800 $200 $300 $200 $10 $35N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0

Embedded $7,350 $14,700 Embedded $7,350 $14,700 0% 0% 0% 3 Visits Covered in Full 0%Embedded $1,350 $2,700 Embedded $5,600 $11,200 20% 20% 20% 20% 20%N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0N/A $0 $0 Embedded $2,300 $4,600 $200 $500 $200 $15 $45N/A $0 $0 N/A $0 $0 $0 $0 $0 $0 $0Embedded $5,500 $11,000 Embedded $6,550 $13,100 50% 50% 50% 50% 50%Embedded $4,000 $8,000 Embedded $7,150 $14,300 50% 50% 50% 50% 50%Embedded $2,000 $4,000 Embedded $6,750 $13,500 $250 $1,500 $100 $30 $50


then $35 after DD $55Embedded $600 $1,200 Embedded $4,000 $8,000 $150 $1,000 $100 $25 $40


thern $25 DD $40N/A $0 $0 Embedded $2,000 $4,000 $100 $500 $100 $15 $35Embedded $4,500 $9,000 Embedded $7,350 $14,700 $500 $1,500 $300 $40 $80

Embedded $5,100 $10,200 Embedded $7,150 $14,300 40% 40% 40%3 visit at $0 No DD, then

40% after DD 40%Embedded $5,900 $11,800 Embedded $6,550 $13,100 $500 30% $100 $30 $50Embedded $6,550 $13,100 Embedded $6,550 $13,100 0% 0% 0% 0% 0%

Embedded $7,350 $14,700 Embedded $7,350 $14,700 0% 0% 0% $30 no DD $0Embedded $1,800 $3,600 Embedded $6,800 $13,600 $500 20% $300 $40 no DD $60


then $40 no DD $70Aggregate $2,500 $5,000 Embedded $5,000 $10,000 $300 $500 $200 $30 $60Embedded $6,550 $13,100 Embedded $6,550 $13,100 0% 0% 0% $30 no DD $0

Embedded $950 $1,900 Embedded $5,500 $11,000 $350 no DD $500 $2003 visits at $0 No DD,

then $15 No DD $50Aggregate $1,350 $2,700 Embedded $4,100 $8,200 $75 $400 $100 $5 $25N/A $0 $0 Embedded $6,750 $13,500 $500 $1,000 $300 $40 $50

Page 11


MVP Form IDNY-HMO-DG-005-N (2018)NY-HMO-DG-008-N (2018)NY-HMO-DG-009-N (2018)

NY-HMO-DP-001-N (2018)NY-HMO-DP-002-N (2018)NY-HMOH-DB-001-NN (2018)NY-HMOH-DS-001-NN (2018)NY-HMOH-DG-001-NN (2018)NY-HMO-DP-001-NN (2018)NY-POS-DP-001-S (2018)

NY-HMO-DC-001-S (2018)NY-HMOH-DB-001-S-CO (2018)NY-HMO-DB-002-S-CO (2018)NY-HMO-DS-001-S-CO (2018)

NY-HMO-DS-002-S-CO (2018)NY-HMO-DG-001-S-CO (2018)

NY-HMO-DG-002-S-CO (2018)NY-HMO-DP-001-S-CO (2018)

Exhibit A

Deductible Type

Single Deductible

Medical

Family Deductible

MedicalOOP Max


Family OOP Maximum

Emergency Room

Inpatient Stay/SNF


Specialist Office

Embedded $1,200 $2,400 Embedded $4,700 $9,400 $300 no DD 20% 20% $30 no DD $50 no DDEmbedded $4,000 $8,000 Embedded $7,150 $14,300 $150 NO DD 20% 20% $30 no DD $50 no DDEmbedded $4,000 $8,000 Embedded $4,000 $8,000 0% 0% 0% $30 no DD $0

N/A $0 $0 Embedded $2,200 $4,400 $200 $300 $1003 visits at $0 No DD,

then $10 after DD $45N/A $0 $0 Embedded $2,400 $4,800 $200 $300 $200 $10 $35Embedded $3,200 $6,400 Embedded $6,550 $13,100 30% 30% 30% 30% 30%Embedded $2,000 $4,000 Embedded $6,550 $13,100 20% 20% 20% 20% 20%Embedded $1,350 $2,700 Embedded $5,600 $11,200 20% 20% 20% 20% 20%Embedded $0 $0 Embedded $2,300 $4,600 $200 $500 $200 $15 $45N/A $0 $0 Embedded $2,000 $4,000 $100 $500 $100 $15 $35

Embedded $7,350 $14,700 Embedded $7,350 $14,700 0% 0% 0% 3 Visits Covered in Full 0%Embedded $5,500 $11,000 Embedded $6,550 $13,100 50% 50% 50% 50% 50%Embedded $4,000 $8,000 Embedded $7,150 $14,300 50% 50% 50% 50% 50%Embedded $2,000 $4,000 Embedded $6,750 $13,500 $250 $1,500 $100 $30 $50


then $35 after DD $55Embedded $600 $1,200 Embedded $4,000 $8,000 $150 $1,000 $100 $25 $40


thern $25 DD $40N/A $0 $0 Embedded $2,000 $4,000 $100 $500 $100 $15 $35

NOTE:All cost sharing after Deductible unless otherwise noted by "no DD"

Page 12


MVP Form ID





FRNY-HMO-DS1-002-S-73 (2018)

Exhibit A

Dep Thru 29 Coverage

Pediatric Dental Available Via

(2017 and Prior)


(2018 and forward)Tier 1

PrescriptionTier 2

PrescriptionTier 3

PrescriptionPrescription Deductible

IRS Qualified Plan

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 Integrated with Med YesOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $0 $0 $0 $0 Yes

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 Integrated with Med NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $0 $0 $0 $0 No

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $0 $0 $0 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $9 $20 $40 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $6 $15 $30 $0 No

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $40 $80 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $0 $0 $0 $0 No

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $40 $80 $0 No

Page 13


MVP Form ID

FRNY-HMO-DS1-002-S-87 (2018)

FRNY-HMO-DS1-002-S-94 (2018)





Exhibit A



(2017 and Prior)



PrescriptionTier 2

PrescriptionTier 3


IRS Qualified Plan







Page 14


MVP Form ID





FRNY-HMO-DS1-002-N-73 (2018)

FRNY-HMO-DS1-002-N-87 (2018)

Exhibit A



(2017 and Prior)



PrescriptionTier 2

PrescriptionTier 3


IRS Qualified Plan



Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $45 $90 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $0 $0 $0 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $45 $90 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $5 $25 $50 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $5 $15 $35 $0 No


Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $15 $40 $70 Integrated with Med No


Page 15


MVP Form ID

FRNY-HMO-DS1-002-N-94 (2018)


FRNY-HMOH-DS1-003-N-87 (2018)

FRNY-HMOH-DS1-003-N-94 (2018)




Exhibit A



(2017 and Prior)



PrescriptionTier 2

PrescriptionTier 3


IRS Qualified Plan


Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $45 $90 Integrated with Med YesOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $0 $0 $0 $0 YesOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $40 $70 Integrated with Med Yes

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $5 $40 $60 Integrated with Med Yes

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $5 $15 $35 Integrated with Med Yes

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $40 $60 $100 Brand Only NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $0 $0 $0 $0 No



Page 16


MVP Form ID









Exhibit A



(2017 and Prior)



PrescriptionTier 2

PrescriptionTier 3


IRS Qualified Plan


Not Available Stand Alone Dental Carrier Stand Alone Dental Carrier 0% 0% 0% Integrated with Med NoOptional Rider N/A Stand Alone Dental Carrier $10 $40 $60 Integrated with Med YesOptional Rider N/A Stand Alone Dental Carrier $0 $0 $0 $0 YesOptional Rider N/A Stand Alone Dental Carrier $5 $30 $50 $0 NoOptional Rider N/A Stand Alone Dental Carrier $0 $0 $0 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 Integrated with Med YesOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 Integrated with Med NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 $0 No


Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $30 $60 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $45 $90 $200 No

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $5 $60 $80 Integrated with Med NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $45 $90 Integrated with Med YesOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier 0% 0% 0% Integrated with Med Yes

Optional Rider N/A Stand Alone Dental Carrier 25 No DD $0 $0 Brand subject to

Medical DD NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $45 $90 $0 No

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $15 $40 $70 Integrated with Med NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $45 $90 Integrated with Med YesOptional Rider N/A Stand Alone Dental Carrier $10 $40 $60 $0 No

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $40 $60 $100 Brand Only NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $5 $15 $25 Integrated with Med YesOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $40 $60 $0 No

Page 17







Exhibit A



(2017 and Prior)



PrescriptionTier 2

PrescriptionTier 3


IRS Qualified Plan

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $5 $30 $50 $0 NoOptional Rider N/A Stand Alone Dental Carrier $10 $35 $70 $0 NoOptional Rider N/A Stand Alone Dental Carrier $10 $40 $80 $0 No

Optional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $40 $60 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $5 $30 $50 $0 NoOptional Rider N/A Stand Alone Dental Carrier $10 $50 $80 Integrated with Med YesOptional Rider N/A Stand Alone Dental Carrier $10 $40 $60 Integrated with Med YesOptional Rider N/A Stand Alone Dental Carrier $10 $40 $60 Integrated with Med YesOptional Rider N/A Stand Alone Dental Carrier $5 $30 $50 $0 NoOptional Rider Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $30 $60 $0 No

Not Available Stand Alone Dental Carrier Stand Alone Dental Carrier 0% 0% 0% Integrated with Med NoNot Available Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 Integrated with Med YesNot Available Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 Integrated with Med NoNot Available Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 $0 No

Not Available Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $40 $80 $0 NoNot Available Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 $0 No

Not Available Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $35 $70 $0 NoNot Available Stand Alone Dental Carrier Stand Alone Dental Carrier $10 $30 $60 $0 No


Page 18


MVP Form ID





FRNY-HMO-DS1-002-S-73 (2018)

Exhibit A

Out of Network

Single Deductible

Family Deductible Coinsurance

Single Out of Pocket Max

Family Out of Pocket

Max Comments

Includes Benefits in Addition to

EHB

N/A N/A N/A N/A N/A

Eligible American Indians, as determined by the Exchange, are exempt from Cost-Sharing requirements when Covered Services are rendered by an Indian Health Service (IHS), Indian Tribe, Tribal Organization, or Urban Indian Organization (UIO) or through Referral under contract health services. Yes

N/A N/A N/A N/A N/A Yes

N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A


N/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A Yes

N/A N/A N/A N/A N/A




Page 19


MVP Form ID

FRNY-HMO-DS1-002-S-87 (2018)

FRNY-HMO-DS1-002-S-94 (2018)





Exhibit A

Out of Network

Single Deductible




Max Comments


EHB



N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A



Page 20


MVP Form ID





FRNY-HMO-DS1-002-N-73 (2018)

FRNY-HMO-DS1-002-N-87 (2018)

Exhibit A

Out of Network

Single Deductible




Max Comments


EHB

N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A





Page 21


MVP Form ID

FRNY-HMO-DS1-002-N-94 (2018)


FRNY-HMOH-DS1-003-N-87 (2018)

FRNY-HMOH-DS1-003-N-94 (2018)




Exhibit A

Out of Network

Single Deductible




Max Comments


EHB


N/A N/A N/A N/A N/A


N/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A Yes



N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A



Page 22


MVP Form ID









Exhibit A

Out of Network

Single Deductible




Max Comments


EHB

N/A N/A N/A N/A N/A



N/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A Yes


N/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A Yes





Page 23







Exhibit A

Out of Network

Single Deductible




Max Comments


EHBN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A Yes

N/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A YesN/A N/A N/A N/A N/A Yes

$1,000 $2,000 20% $3,000 $5,000 Yes





Page 24

MVP Health Plan, Inc. Exhibit A.1Rider DescriptionsEffective January 1, 2018Version 8/16/2017

MVP Form IDMVP Form for Rate Distinction Benefit Description

Small vs Individual


Available to Child Only Policies


Exchange

FRNY-X-100 FRNY-X-100 Dependent Through Age 29 IndividualStandard & Non-Standard

All Metal Levels excluding "Catastrophic" No On

NY-X-100 NY-X-100 Dependent Through Age 29 IndividualStandard & Non-Standard

All Metal Levels excluding "Catastrophic" No Off

NY-X-USNF NY-X-USNF Unlimited Skilled Nursing Facility IndividualStandard & Non-Standard

All Metal Levels excluding "Catastrophic" Yes Off

Page 25

MVP Health Plan, Inc. Exhibit BHIOS Plan ID to FormsEffective January 1, 2018Version 8/16/2017

HIOS Plan IDSmall vs Individual

Standard vs Non-Standard Metal Level Off Exchange On Exchange AI/AN < 300 FPL

56184NY0140010 Individual Standard Bronze NY-HMOH-DB-001-S (2018) FRNY-HMOH-DB-001-S (2018) FRNY-HMOH-DBA1-001-S (2018)56184NY0140011 Individual Standard Bronze NY-HMOH-DB-001-S (2018) FRNY-HMOH-DB-001-S (2018) FRNY-HMOH-DBA1-001-S (2018)56184NY0140012 Individual Standard Silver NY-HMO-DS-001-S (2018) FRNY-HMO-DS-001-S (2018) FRNY-HMO-DSA1-001-S (2018)56184NY0140013 Individual Standard Silver NY-HMO-DS-001-S (2018) FRNY-HMO-DS-001-S (2018) FRNY-HMO-DSA1-001-S (2018)56184NY0140014 Individual Standard Gold NY-HMO-DG-001-S (2018) FRNY-HMO-DG-001-S (2018) FRNY-HMO-DGA1-001-S (2018)56184NY0140015 Individual Standard Gold NY-HMO-DG-001-S (2018) FRNY-HMO-DG-001-S (2018) FRNY-HMO-DGA1-001-S (2018)56184NY0140016 Individual Standard Platinum NY-HMO-DP-001-S (2018) FRNY-HMO-DP-001-S (2018) FRNY-HMO-DPA1-001-S (2018)56184NY0140017 Individual Standard Platinum NY-HMO-DP-001-S (2018) FRNY-HMO-DP-001-S (2018) FRNY-HMO-DPA1-001-S (2018)56184NY0140018 Individual Standard Platinum NY-POS-DP-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140019 Individual Standard Platinum NY-POS-DP-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140020 Individual Standard Bronze NY-HMOH-DB-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140021 Individual Standard Bronze NY-HMOH-DB-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140022 Individual Standard Silver NY-HMO-DS-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140023 Individual Standard Silver NY-HMO-DS-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140024 Individual Standard Gold NY-HMO-DG-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140025 Individual Standard Gold NY-HMO-DG-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140026 Individual Standard Platinum NY-HMO-DP-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140027 Individual Standard Platinum NY-HMO-DP-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140028 Individual Standard Platinum NY-POS-DP-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140029 Individual Standard Platinum NY-POS-DP-001-S (2018) N/A - Not Available N/A - Not Available56184NY0140030 Individual Standard Bronze NY-HMO-DB-002-S (2018) FRNY-HMO-DB-002-S (2018) FRNY-HMO-DBA1-002-S (2018)56184NY0140031 Individual Standard Bronze NY-HMO-DB-002-S (2018) FRNY-HMO-DB-002-S (2018) FRNY-HMO-DBA1-002-S (2018)56184NY0140032 Individual Standard Bronze NY-HMO-DB-002-S (2018) N/A - Not Available N/A - Not Available56184NY0140033 Individual Standard Bronze NY-HMO-DB-002-S (2018) N/A - Not Available N/A - Not Available56184NY0140034 Individual Standard Gold NY-HMO-DG-002-S (2018) FRNY-HMO-DG-002-S (2018) FRNY-HMO-DGA1-002-S (2018)56184NY0140035 Individual Standard Gold NY-HMO-DG-002-S (2018) FRNY-HMO-DG-002-S (2018) FRNY-HMO-DGA1-002-S (2018)56184NY0140036 Individual Standard Gold NY-HMO-DG-002-S (2018) N/A - Not Available N/A - Not Available56184NY0140037 Individual Standard Gold NY-HMO-DG-002-S (2018) N/A - Not Available N/A - Not Available56184NY0140038 Individual Standard Silver NY-HMO-DS-002-S (2018) FRNY-HMO-DS-002-S (2018) FRNY-HMO-DSA1-002-S (2018)56184NY0140039 Individual Standard Silver NY-HMO-DS-002-S (2018) FRNY-HMO-DS-002-S (2018) FRNY-HMO-DSA1-002-S (2018)56184NY0140040 Individual Standard Silver NY-HMO-DS-002-S (2018) N/A - Not Available N/A - Not Available56184NY0140041 Individual Standard Silver NY-HMO-DS-002-S (2018) N/A - Not Available N/A - Not Available56184NY0150008 Individual Non-Standard Bronze NY-HMO-DB-002-N (2018) FRNY-HMO-DB-002-N (2018) FRNY-HMO-DBA1-002-N (2018)56184NY0150009 Individual Non-Standard Silver NY-HMO-DS-002-N (2018) FRNY-HMO-DS-002-N (2018) FRNY-HMO-DSA1-002-N (2018)56184NY0150010 Individual Non-Standard Gold NY-HMO-DG-001-N (2018) FRNY-HMO-DG-001-N (2018) FRNY-HMO-DGA1-001-N (2018)

Page 26




56184NY0150011 Individual Non-Standard Platinum NY-HMO-DP-001-N (2018) FRNY-HMO-DP-001-N (2018) FRNY-HMO-DPA1-001-N (2018)56184NY0150012 Individual Non-Standard Bronze NY-HMO-DB-001-N (2018) FRNY-HMO-DB-001-N (2018) FRNY-HMO-DBA1-001-N (2018)56184NY0150013 Individual Non-Standard Silver NY-HMO-DS-001-N (2018) FRNY-HMO-DS-001-N (2018) FRNY-HMO-DSA1-001-N (2018)56184NY0150014 Individual Non-Standard Platinum NY-HMO-DP-002-N (2018) FRNY-HMO-DP-002-N (2018) FRNY-HMO-DPA1-002-N (2018)56184NY0150015 Individual Non-Standard Bronze NY-HMO-DB-002-N (2018) FRNY-HMO-DB-002-N (2018) FRNY-HMO-DBA1-002-N (2018)56184NY0150016 Individual Non-Standard Silver NY-HMO-DS-001-N (2018) FRNY-HMO-DS-001-N (2018) FRNY-HMO-DSA1-001-N (2018)56184NY0150017 Individual Non-Standard Silver NY-HMO-DS-002-N (2018) FRNY-HMO-DS-002-N (2018) FRNY-HMO-DSA1-002-N (2018)56184NY0150018 Individual Non-Standard Gold NY-HMO-DG-001-N (2018) FRNY-HMO-DG-001-N (2018) FRNY-HMO-DGA1-001-N (2018)56184NY0150019 Individual Non-Standard Platinum NY-HMO-DP-001-N (2018) FRNY-HMO-DP-001-N (2018) FRNY-HMO-DPA1-001-N (2018)56184NY0150020 Individual Non-Standard Platinum NY-HMO-DP-002-N (2018) FRNY-HMO-DP-002-N (2018) FRNY-HMO-DPA1-002-N (2018)56184NY0150021 Individual Non-Standard Bronze NY-HMO-DB-001-N (2018) FRNY-HMO-DB-001-N (2018) FRNY-HMO-DBA1-001-N (2018)56184NY0150022 Individual Non-Standard Bronze NY-HMO-DB-002-N (2018) N/A - Not Available N/A - Not Available56184NY0150023 Individual Non-Standard Silver NY-HMO-DS-001-N (2018) N/A - Not Available N/A - Not Available56184NY0150024 Individual Non-Standard Silver NY-HMO-DS-002-N (2018) N/A - Not Available N/A - Not Available56184NY0150025 Individual Non-Standard Gold NY-HMO-DG-001-N (2018) N/A - Not Available N/A - Not Available56184NY0150026 Individual Non-Standard Bronze NY-HMO-DB-001-N (2018) N/A - Not Available N/A - Not Available56184NY0150027 Individual Non-Standard Bronze NY-HMO-DB-002-N (2018) N/A - Not Available N/A - Not Available56184NY0150028 Individual Non-Standard Silver NY-HMO-DS-001-N (2018) N/A - Not Available N/A - Not Available56184NY0150029 Individual Non-Standard Silver NY-HMO-DS-002-N (2018) N/A - Not Available N/A - Not Available56184NY0150030 Individual Non-Standard Gold NY-HMO-DG-001-N (2018) N/A - Not Available N/A - Not Available56184NY0150031 Individual Non-Standard Bronze NY-HMO-DB-001-N (2018) N/A - Not Available N/A - Not Available56184NY0150032 Individual Non-Standard Platinum NY-HMO-DP-001-N (2018) N/A - Not Available N/A - Not Available56184NY0150033 Individual Non-Standard Platinum NY-HMO-DP-001-N (2018) N/A - Not Available N/A - Not Available56184NY0150034 Individual Non-Standard Platinum NY-HMO-DP-002-N (2018) N/A - Not Available N/A - Not Available56184NY0150035 Individual Non-Standard Platinum NY-HMO-DP-002-N (2018) N/A - Not Available N/A - Not Available56184NY0150040 Individual Non-Standard Gold NY-HMO-DG-004-N (2018) N/A - Not Available N/A - Not Available56184NY0150041 Individual Non-Standard Gold NY-HMO-DG-004-N (2018) N/A - Not Available N/A - Not Available56184NY0150042 Individual Non-Standard Gold NY-HMO-DG-004-N (2018) N/A - Not Available N/A - Not Available56184NY0150043 Individual Non-Standard Gold NY-HMO-DG-004-N (2018) N/A - Not Available N/A - Not Available56184NY0150048 Individual Non-Standard Gold NY-HMO-DG-005-N (2018) N/A - Not Available N/A - Not Available56184NY0150049 Individual Non-Standard Gold NY-HMO-DG-005-N (2018) N/A - Not Available N/A - Not Available56184NY0150050 Individual Non-Standard Gold NY-HMO-DG-005-N (2018) N/A - Not Available N/A - Not Available56184NY0150051 Individual Non-Standard Gold NY-HMO-DG-005-N (2018) N/A - Not Available N/A - Not Available56184NY0150072 Individual Non-Standard Gold NY-HMO-DG-008-N (2018) N/A - Not Available N/A - Not Available56184NY0150073 Individual Non-Standard Gold NY-HMO-DG-008-N (2018) N/A - Not Available N/A - Not Available

Page 27




56184NY0150074 Individual Non-Standard Gold NY-HMO-DG-008-N (2018) N/A - Not Available N/A - Not Available56184NY0150075 Individual Non-Standard Gold NY-HMO-DG-008-N (2018) N/A - Not Available N/A - Not Available56184NY0150076 Individual Non-Standard Bronze NY-HMO-DB-008-N (2018) N/A - Not Available N/A - Not Available56184NY0150077 Individual Non-Standard Bronze NY-HMO-DB-008-N (2018) N/A - Not Available N/A - Not Available56184NY0150078 Individual Non-Standard Bronze NY-HMO-DB-008-N (2018) N/A - Not Available N/A - Not Available56184NY0150079 Individual Non-Standard Bronze NY-HMO-DB-008-N (2018) N/A - Not Available N/A - Not Available56184NY0150080 Individual Non-Standard Platinum NY-HMO-DP-001-NN (2018) FRNY-HMO-DP-001-NN (2018) FRNY-HMO-DPA1-001-NN (2018)56184NY0150081 Individual Non-Standard Platinum NY-HMO-DP-001-NN (2018) FRNY-HMO-DP-001-NN (2018) FRNY-HMO-DPA1-001-NN (2018)56184NY0150082 Individual Non-Standard Platinum NY-HMO-DP-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0150083 Individual Non-Standard Platinum NY-HMO-DP-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0150084 Individual Non-Standard Silver NY-HMO-DS-010-N (2018) N/A - Not Available N/A - Not Available56184NY0150085 Individual Non-Standard Silver NY-HMO-DS-010-N (2018) N/A - Not Available N/A - Not Available56184NY0150086 Individual Non-Standard Silver NY-HMO-DS-010-N (2018) N/A - Not Available N/A - Not Available56184NY0150087 Individual Non-Standard Silver NY-HMO-DS-010-N (2018) N/A - Not Available N/A - Not Available56184NY0150088 Individual Non-Standard Gold NY-HMO-DG-009-N (2018) N/A - Not Available N/A - Not Available56184NY0150089 Individual Non-Standard Gold NY-HMO-DG-009-N (2018) N/A - Not Available N/A - Not Available56184NY0150090 Individual Non-Standard Gold NY-HMO-DG-009-N (2018) N/A - Not Available N/A - Not Available56184NY0150091 Individual Non-Standard Gold NY-HMO-DG-009-N (2018) N/A - Not Available N/A - Not Available56184NY0190005 Individual Standard Bronze NY-HMOH-DB-001-S-CO (2018) FRNY-HMOH-DB-001-S (2018) FRNY-HMOH-DBA1-001-S (2018)56184NY0190006 Individual Standard Silver NY-HMO-DS-001-S-CO (2018) FRNY-HMO-DS-001-S (2018) FRNY-HMO-DSA1-001-S (2018)56184NY0190007 Individual Standard Gold NY-HMO-DG-001-S-CO (2018) FRNY-HMO-DG-001-S (2018) FRNY-HMO-DGA1-001-S (2018)56184NY0190008 Individual Standard Platinum NY-HMO-DP-001-S-CO (2018) FRNY-HMO-DP-001-S (2018) FRNY-HMO-DPA1-001-S (2018)56184NY0190009 Individual Standard Bronze NY-HMOH-DB-001-S-CO (2018) N/A - Not Available N/A - Not Available56184NY0190010 Individual Standard Silver NY-HMO-DS-001-S-CO (2018) N/A - Not Available N/A - Not Available56184NY0190011 Individual Standard Gold NY-HMO-DG-001-S-CO (2018) N/A - Not Available N/A - Not Available56184NY0190012 Individual Standard Platinum NY-HMO-DP-001-S-CO (2018) N/A - Not Available N/A - Not Available56184NY0190013 Individual Standard Bronze NY-HMO-DB-002-S-CO (2018) FRNY-HMO-DB-002-S (2018) FRNY-HMO-DBA1-002-S (2018)56184NY0190014 Individual Standard Bronze NY-HMO-DB-002-S-CO (2018) N/A - Not Available N/A - Not Available56184NY0190015 Individual Standard Gold NY-HMO-DG-002-S-CO (2018) FRNY-HMO-DG-002-S (2018) FRNY-HMO-DGA1-002-S (2018)56184NY0190016 Individual Standard Gold NY-HMO-DG-002-S-CO (2018) N/A - Not Available N/A - Not Available56184NY0190017 Individual Standard Silver NY-HMO-DS-002-S-CO (2018) FRNY-HMO-DS-002-S (2018) FRNY-HMO-DSA1-002-S (2018)56184NY0190018 Individual Standard Silver NY-HMO-DS-002-S-CO (2018) N/A - Not Available N/A - Not Available56184NY0200004 Individual Non-Standard Bronze NY-HMOH-DB-003-N (2018) FRNY-HMOH-DB-003-N (2018) FRNY-HMOH-DBA1-003-N (2018)56184NY0200005 Individual Non-Standard Silver NY-HMOH-DS-003-N (2018) FRNY-HMOH-DS-003-N (2018) FRNY-HMOH-DSA1-003-N (2018)56184NY0200006 Individual Non-Standard Gold NY-HMOH-DG-002-N (2018) FRNY-HMOH-DG-002-N (2018) FRNY-HMOH-DGA1-002-N (2018)

Page 28




56184NY0200007 Individual Non-Standard Bronze NY-HMOH-DB-003-N (2018) FRNY-HMOH-DB-003-N (2018) FRNY-HMOH-DBA1-003-N (2018)56184NY0200008 Individual Non-Standard Silver NY-HMOH-DS-003-N (2018) FRNY-HMOH-DS-003-N (2018) FRNY-HMOH-DSA1-003-N (2018)56184NY0200009 Individual Non-Standard Gold NY-HMOH-DG-002-N (2018) FRNY-HMOH-DG-002-N (2018) FRNY-HMOH-DGA1-002-N (2018)56184NY0200010 Individual Non-Standard Bronze NY-HMOH-DB-003-N (2018) N/A - Not Available N/A - Not Available56184NY0200011 Individual Non-Standard Silver NY-HMOH-DS-003-N (2018) N/A - Not Available N/A - Not Available56184NY0200012 Individual Non-Standard Gold NY-HMOH-DG-002-N (2018) N/A - Not Available N/A - Not Available56184NY0200013 Individual Non-Standard Bronze NY-HMOH-DB-003-N (2018) N/A - Not Available N/A - Not Available56184NY0200014 Individual Non-Standard Silver NY-HMOH-DS-003-N (2018) N/A - Not Available N/A - Not Available56184NY0200015 Individual Non-Standard Gold NY-HMOH-DG-002-N (2018) N/A - Not Available N/A - Not Available56184NY0200028 Individual Non-Standard Bronze NY-HMOH-DB-006-N (2018) N/A - Not Available N/A - Not Available56184NY0200029 Individual Non-Standard Bronze NY-HMOH-DB-006-N (2018) N/A - Not Available N/A - Not Available56184NY0200030 Individual Non-Standard Bronze NY-HMOH-DB-006-N (2018) N/A - Not Available N/A - Not Available56184NY0200031 Individual Non-Standard Bronze NY-HMOH-DB-006-N (2018) N/A - Not Available N/A - Not Available56184NY0200036 Individual Non-Standard Silver NY-HMOH-DS-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200037 Individual Non-Standard Silver NY-HMOH-DS-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200038 Individual Non-Standard Silver NY-HMOH-DS-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200039 Individual Non-Standard Silver NY-HMOH-DS-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200032 Individual Non-Standard Gold NY-HMOH-DG-001-NN (2018) FRNY-HMOH-DG-001-NN (2018) FRNY-HMOH-DGA1-001-NN (2018)56184NY0200033 Individual Non-Standard Gold NY-HMOH-DG-001-NN (2018) FRNY-HMOH-DG-001-NN (2018) FRNY-HMOH-DGA1-001-NN (2018)56184NY0200034 Individual Non-Standard Gold NY-HMOH-DG-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200035 Individual Non-Standard Gold NY-HMOH-DG-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200040 Individual Non-Standard Bronze NY-HMOH-DB-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200041 Individual Non-Standard Bronze NY-HMOH-DB-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200042 Individual Non-Standard Bronze NY-HMOH-DB-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0200043 Individual Non-Standard Bronze NY-HMOH-DB-001-NN (2018) N/A - Not Available N/A - Not Available56184NY0220002 Individual Standard Catastrophic NY-HMO-DC-001-S (2018) FRNY-HMO-DC-001-S (2018) N/A - Not Available

Page 29

MVP Health Plan, Inc.HIOS Plan ID to FormsEffective January 1, 2018Version 8/16/2017

HIOS Plan ID56184NY014001056184NY014001156184NY014001256184NY014001356184NY014001456184NY014001556184NY014001656184NY014001756184NY014001856184NY014001956184NY014002056184NY014002156184NY014002256184NY014002356184NY014002456184NY014002556184NY014002656184NY014002756184NY014002856184NY014002956184NY014003056184NY014003156184NY014003256184NY014003356184NY014003456184NY014003556184NY014003656184NY014003756184NY014003856184NY014003956184NY014004056184NY014004156184NY015000856184NY015000956184NY0150010

Exhibit B

AI/AN > 300 FPL Subsidy Level = 73% Subsidy Level = 87% Subsidy Level = 94%FRNY-HMOH-DB-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMOH-DB-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DS-001-S (2018) FRNY-HMO-DS1-001-S-73 (2018) FRNY-HMO-DS1-001-S-87 (2018) FRNY-HMO-DS1-001-S-94 (2018)FRNY-HMO-DS-001-S (2018) FRNY-HMO-DS1-001-S-73 (2018) FRNY-HMO-DS1-001-S-87 (2018) FRNY-HMO-DS1-001-S-94 (2018)FRNY-HMO-DG-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DG-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DP-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DP-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DB-002-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DB-002-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DG-002-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DG-002-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DS-002-S (2018) FRNY-HMO-DS1-002-S-73 (2018) FRNY-HMO-DS1-002-S-87 (2018) FRNY-HMO-DS1-002-S-94 (2018)FRNY-HMO-DS-002-S (2018) FRNY-HMO-DS1-002-S-73 (2018) FRNY-HMO-DS1-002-S-87 (2018) FRNY-HMO-DS1-002-S-94 (2018)N/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DB-002-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DS-002-N (2018) FRNY-HMO-DS1-002-N-73 (2018) FRNY-HMO-DS1-002-N-87 (2018) FRNY-HMO-DS1-002-N-94 (2018)FRNY-HMO-DG-001-N (2018) N/A - Not Available N/A - Not Available N/A - Not Available

Page 30



Exhibit B

AI/AN > 300 FPL Subsidy Level = 73% Subsidy Level = 87% Subsidy Level = 94%FRNY-HMO-DP-001-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DB-001-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DS-001-N (2018) FRNY-HMO-DS1-001-N-73 (2018) FRNY-HMO-DS1-001-N-87 (2018) FRNY-HMO-DS1-001-N-94 (2018)FRNY-HMO-DP-002-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DB-002-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DS-001-N (2018) FRNY-HMO-DS1-001-N-73 (2018) FRNY-HMO-DS1-001-N-87 (2018) FRNY-HMO-DS1-001-N-94 (2018)FRNY-HMO-DS-002-N (2018) FRNY-HMO-DS1-002-N-73 (2018) FRNY-HMO-DS1-002-N-87 (2018) FRNY-HMO-DS1-002-N-94 (2018)FRNY-HMO-DG-001-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DP-001-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DP-002-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DB-001-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not Available

Page 31



Exhibit B

AI/AN > 300 FPL Subsidy Level = 73% Subsidy Level = 87% Subsidy Level = 94%N/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DP-001-NN (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DP-001-NN (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMOH-DB-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DS-001-S (2018) FRNY-HMO-DS1-001-S-73 (2018) N/A - Not Available N/A - Not AvailableFRNY-HMO-DG-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DP-001-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DB-002-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DG-002-S (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMO-DS-002-S (2018) FRNY-HMO-DS1-002-S-73 (2018) N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMOH-DB-003-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMOH-DS-003-N (2018) FRNY-HMOH-DS1-003-N-73 (2018) FRNY-HMOH-DS1-003-N-87 (2018) FRNY-HMOH-DS1-003-N-94 (2018)FRNY-HMOH-DG-002-N (2018) N/A - Not Available N/A - Not Available N/A - Not Available

Page 32


HIOS Plan ID56184NY020000756184NY020000856184NY020000956184NY020001056184NY020001156184NY020001256184NY020001356184NY020001456184NY020001556184NY020002856184NY020002956184NY020003056184NY020003156184NY020003656184NY020003756184NY020003856184NY020003956184NY020003256184NY020003356184NY020003456184NY020003556184NY020004056184NY020004156184NY020004256184NY020004356184NY0220002

Exhibit B

AI/AN > 300 FPL Subsidy Level = 73% Subsidy Level = 87% Subsidy Level = 94%FRNY-HMOH-DB-003-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableFRNY-HMOH-DS-003-N (2018) FRNY-HMOH-DS1-003-N-73 (2018) FRNY-HMOH-DS1-003-N-87 (2018) FRNY-HMOH-DS1-003-N-94 (2018)FRNY-HMOH-DG-002-N (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableNY-HMOH-DG-001-NN (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableNY-HMOH-DG-001-NN (2018) N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not AvailableN/A - Not Available N/A - Not Available N/A - Not Available N/A - Not Available

Page 33



Exhibit B

Rate ID: On Exchange

Dependent thru 29 Form ID

Domestic Partner Form ID

Pediatric Dental Coverage Form ID

Religious Exemption for Family Planning Form ID

Unlimited Skilled Nursing Facility Form ID

N/A N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/A

Page 34



Exhibit B







FRNY-X-100 N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/A

Page 35



Exhibit B







N/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/AFRNY-X-100 N/A - In Base N/A N/A N/A

Page 36



Exhibit B







N/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A - In Base N/A N/A N/A

Page 37



Exhibit B

Rate ID: Off Exchange






N/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/A

Page 38



Exhibit B







NY-X-100 N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/A

Page 39



Exhibit B







N/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A N/AN/A N/A N/A N/A NY-X-USNFN/A N/A N/A N/A NY-X-USNFN/A N/A N/A N/A NY-X-USNFN/A N/A N/A N/A NY-X-USNFN/A N/A N/A N/A N/AN/A N/A N/A N/A NY-X-USNFN/A N/A N/A N/A N/AN/A N/A N/A N/A NY-X-USNFN/A N/A N/A N/A N/AN/A N/A N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/A

Page 40



Exhibit B







N/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/ANY-X-100 N/A - In Base N/A N/A N/AN/A N/A - In Base N/A N/A NY-X-USNFNY-X-100 N/A - In Base N/A N/A NY-X-USNFN/A N/A - In Base N/A N/A N/A

Page 41

MVP Health Plan, Inc. Exhibit CPremiumsEffective January 1, 2018Version 8/16/2017

2018

MVP Form ID Benefit DescriptionSmall vs Individual

Standard vs Non-Standard Metal Level Rate Region Single

Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 1 Albany $428.16 $856.32 $727.87 $1,220.26

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 1 Albany $428.16 $856.32 $727.87 $1,220.26

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 1 Albany $428.82 $857.64 $728.99 $1,222.14

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 1 Albany $428.82 $857.64 $728.99 $1,222.14

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 1 Albany $552.69 $1,105.38 $939.57 $1,575.17

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 1 Albany $552.69 $1,105.38 $939.57 $1,575.17

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 1 Albany $552.69 $1,105.38 $939.57 $1,575.17FRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 1 Albany $552.69 $1,105.38 $939.57 $1,575.17FRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 1 Albany $552.69 $1,105.38 $939.57 $1,575.17FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 1 Albany $565.26 $1,130.52 $960.94 $1,610.99

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 1 Albany $565.26 $1,130.52 $960.94 $1,610.99

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 1 Albany $565.26 $1,130.52 $960.94 $1,610.99

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 1 Albany $565.26 $1,130.52 $960.94 $1,610.99

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 1 Albany $565.26 $1,130.52 $960.94 $1,610.99FRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 1 Albany $636.84 $1,273.68 $1,082.63 $1,814.99

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 1 Albany $636.84 $1,273.68 $1,082.63 $1,814.99FRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 1 Albany $641.83 $1,283.66 $1,091.11 $1,829.22

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 1 Albany $641.83 $1,283.66 $1,091.11 $1,829.22

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 1 Albany $737.29 $1,474.58 $1,253.39 $2,101.28

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 1 Albany $737.29 $1,474.58 $1,253.39 $2,101.28

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 1 Albany $444.66 $889.32 $755.92 $1,267.28

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 1 Albany $444.66 $889.32 $755.92 $1,267.28

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 1 Albany $436.08 $872.16 $741.34 $1,242.83

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 1 Albany $436.08 $872.16 $741.34 $1,242.83

Page 42


2018



Single + Spouse

Single + Child(ren)


FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 1 Albany $440.70 $881.40 $749.19 $1,256.00

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 1 Albany $440.70 $881.40 $749.19 $1,256.00

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 1 Albany $561.77 $1,123.54 $955.01 $1,601.04

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 1 Albany $561.77 $1,123.54 $955.01 $1,601.04

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 1 Albany $561.77 $1,123.54 $955.01 $1,601.04



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 1 Albany $522.67 $1,045.34 $888.54 $1,489.61

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 1 Albany $522.67 $1,045.34 $888.54 $1,489.61




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 1 Albany $526.86 $1,053.72 $895.66 $1,501.55

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 1 Albany $526.86 $1,053.72 $895.66 $1,501.55

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 1 Albany $526.86 $1,053.72 $895.66 $1,501.55



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 1 Albany $625.43 $1,250.86 $1,063.23 $1,782.48

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 1 Albany $625.43 $1,250.86 $1,063.23 $1,782.48

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 1 Albany $611.17 $1,222.34 $1,038.99 $1,741.83

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 1 Albany $611.17 $1,222.34 $1,038.99 $1,741.83

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 1 Albany $730.46 $1,460.92 $1,241.78 $2,081.81

Page 43


2018



Single + Spouse

Single + Child(ren)


FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 1 Albany $730.46 $1,460.92 $1,241.78 $2,081.81

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 1 Albany $733.49 $1,466.98 $1,246.93 $2,090.45

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 1 Albany $733.49 $1,466.98 $1,246.93 $2,090.45

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 1 Albany $253.02 $506.04 $430.13 $721.11

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 1 Albany $598.88 $1,197.76 $1,018.10 $1,706.81

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 1 Albany $598.88 $1,197.76 $1,018.10 $1,706.81

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 1 Albany $756.20 $1,512.40 $1,285.54 $2,155.17

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 1 Albany $756.20 $1,512.40 $1,285.54 $2,155.17

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 2 Buffalo $396.72 $793.44 $674.42 $1,130.65

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 2 Buffalo $396.72 $793.44 $674.42 $1,130.65

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 2 Buffalo $397.33 $794.66 $675.46 $1,132.39

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 2 Buffalo $397.33 $794.66 $675.46 $1,132.39

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 2 Buffalo $512.11 $1,024.22 $870.59 $1,459.51

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 2 Buffalo $512.11 $1,024.22 $870.59 $1,459.51

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 2 Buffalo $512.11 $1,024.22 $870.59 $1,459.51FRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 2 Buffalo $512.11 $1,024.22 $870.59 $1,459.51FRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 2 Buffalo $512.11 $1,024.22 $870.59 $1,459.51FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 2 Buffalo $523.76 $1,047.52 $890.39 $1,492.72

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 2 Buffalo $523.76 $1,047.52 $890.39 $1,492.72

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 2 Buffalo $523.76 $1,047.52 $890.39 $1,492.72

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 2 Buffalo $523.76 $1,047.52 $890.39 $1,492.72

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 2 Buffalo $523.76 $1,047.52 $890.39 $1,492.72FRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 2 Buffalo $590.08 $1,180.16 $1,003.14 $1,681.73FRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 2 Buffalo $594.70 $1,189.40 $1,010.99 $1,694.90

Page 44


2018



Single + Spouse

Single + Child(ren)


FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 2 Buffalo $594.70 $1,189.40 $1,010.99 $1,694.90

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 2 Buffalo $590.08 $1,180.16 $1,003.14 $1,681.73FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 2 Buffalo $683.15 $1,366.30 $1,161.36 $1,946.98

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 2 Buffalo $683.15 $1,366.30 $1,161.36 $1,946.98

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 2 Buffalo $412.01 $824.02 $700.42 $1,174.23

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 2 Buffalo $412.01 $824.02 $700.42 $1,174.23

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 2 Buffalo $404.06 $808.12 $686.90 $1,151.57

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 2 Buffalo $404.06 $808.12 $686.90 $1,151.57

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 2 Buffalo $408.34 $816.68 $694.18 $1,163.77

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 2 Buffalo $408.34 $816.68 $694.18 $1,163.77

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 2 Buffalo $520.52 $1,041.04 $884.88 $1,483.48

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 2 Buffalo $520.52 $1,041.04 $884.88 $1,483.48

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 2 Buffalo $520.52 $1,041.04 $884.88 $1,483.48



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 2 Buffalo $484.29 $968.58 $823.29 $1,380.23

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 2 Buffalo $484.29 $968.58 $823.29 $1,380.23

FRNY-HMO-DS1-002-N-73 (2018)Non-Standard Silver 2 CSR AV73 Individual Non-Standard Silver 2 Buffalo $484.29 $968.58 $823.29 $1,380.23



FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 2 Buffalo $488.17 $976.34 $829.89 $1,391.28

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 2 Buffalo $488.17 $976.34 $829.89 $1,391.28

Page 45


2018



Single + Spouse

Single + Child(ren)


FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 2 Buffalo $488.17 $976.34 $829.89 $1,391.28



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 2 Buffalo $579.51 $1,159.02 $985.17 $1,651.60

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 2 Buffalo $579.51 $1,159.02 $985.17 $1,651.60

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 2 Buffalo $566.30 $1,132.60 $962.71 $1,613.96

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 2 Buffalo $566.30 $1,132.60 $962.71 $1,613.96

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 2 Buffalo $676.82 $1,353.64 $1,150.59 $1,928.94

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 2 Buffalo $676.82 $1,353.64 $1,150.59 $1,928.94

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 2 Buffalo $679.64 $1,359.28 $1,155.39 $1,936.97

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 2 Buffalo $679.64 $1,359.28 $1,155.39 $1,936.97

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 2 Buffalo $234.44 $468.88 $398.55 $668.15

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 2 Buffalo $554.91 $1,109.82 $943.35 $1,581.49

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 2 Buffalo $554.91 $1,109.82 $943.35 $1,581.49

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 2 Buffalo $700.68 $1,401.36 $1,191.16 $1,996.94

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 2 Buffalo $700.68 $1,401.36 $1,191.16 $1,996.94

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 3 Mid-Hudson $550.36 $1,100.72 $935.61 $1,568.53

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 3 Mid-Hudson $550.36 $1,100.72 $935.61 $1,568.53

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 3 Mid-Hudson $551.21 $1,102.42 $937.06 $1,570.95

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 3 Mid-Hudson $551.21 $1,102.42 $937.06 $1,570.95

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 3 Mid-Hudson $710.44 $1,420.88 $1,207.75 $2,024.75

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 3 Mid-Hudson $710.44 $1,420.88 $1,207.75 $2,024.75

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 3 Mid-Hudson $710.44 $1,420.88 $1,207.75 $2,024.75FRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 3 Mid-Hudson $710.44 $1,420.88 $1,207.75 $2,024.75

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FRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 3 Mid-Hudson $710.44 $1,420.88 $1,207.75 $2,024.75FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 3 Mid-Hudson $726.59 $1,453.18 $1,235.20 $2,070.78

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 3 Mid-Hudson $726.59 $1,453.18 $1,235.20 $2,070.78

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 3 Mid-Hudson $726.59 $1,453.18 $1,235.20 $2,070.78

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 3 Mid-Hudson $726.59 $1,453.18 $1,235.20 $2,070.78

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 3 Mid-Hudson $726.59 $1,453.18 $1,235.20 $2,070.78FRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 3 Mid-Hudson $818.60 $1,637.20 $1,391.62 $2,333.01

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 3 Mid-Hudson $818.60 $1,637.20 $1,391.62 $2,333.01FRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 3 Mid-Hudson $825.01 $1,650.02 $1,402.52 $2,351.28

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 3 Mid-Hudson $825.01 $1,650.02 $1,402.52 $2,351.28

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 3 Mid-Hudson $947.72 $1,895.44 $1,611.12 $2,701.00

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 3 Mid-Hudson $947.72 $1,895.44 $1,611.12 $2,701.00

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 3 Mid-Hudson $571.57 $1,143.14 $971.67 $1,628.97

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 3 Mid-Hudson $571.57 $1,143.14 $971.67 $1,628.97

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 3 Mid-Hudson $560.54 $1,121.08 $952.92 $1,597.54

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 3 Mid-Hudson $560.54 $1,121.08 $952.92 $1,597.54

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 3 Mid-Hudson $566.48 $1,132.96 $963.02 $1,614.47

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 3 Mid-Hudson $566.48 $1,132.96 $963.02 $1,614.47

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 3 Mid-Hudson $722.11 $1,444.22 $1,227.59 $2,058.01

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 3 Mid-Hudson $722.11 $1,444.22 $1,227.59 $2,058.01

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 3 Mid-Hudson $722.11 $1,444.22 $1,227.59 $2,058.01



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 3 Mid-Hudson $671.85 $1,343.70 $1,142.15 $1,914.77

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FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 3 Mid-Hudson $671.85 $1,343.70 $1,142.15 $1,914.77




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 3 Mid-Hudson $677.23 $1,354.46 $1,151.29 $1,930.11

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 3 Mid-Hudson $677.23 $1,354.46 $1,151.29 $1,930.11

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 3 Mid-Hudson $677.23 $1,354.46 $1,151.29 $1,930.11



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 3 Mid-Hudson $803.94 $1,607.88 $1,366.70 $2,291.23

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 3 Mid-Hudson $803.94 $1,607.88 $1,366.70 $2,291.23

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 3 Mid-Hudson $785.61 $1,571.22 $1,335.54 $2,238.99

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 3 Mid-Hudson $785.61 $1,571.22 $1,335.54 $2,238.99

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 3 Mid-Hudson $938.94 $1,877.88 $1,596.20 $2,675.98

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 3 Mid-Hudson $938.94 $1,877.88 $1,596.20 $2,675.98

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 3 Mid-Hudson $942.84 $1,885.68 $1,602.83 $2,687.09

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 3 Mid-Hudson $942.84 $1,885.68 $1,602.83 $2,687.09

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 3 Mid-Hudson $325.23 $650.46 $552.89 $926.91

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 3 Mid-Hudson $769.82 $1,539.64 $1,308.69 $2,193.99

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 3 Mid-Hudson $769.82 $1,539.64 $1,308.69 $2,193.99

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 3 Mid-Hudson $972.04 $1,944.08 $1,652.47 $2,770.31

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 3 Mid-Hudson $972.04 $1,944.08 $1,652.47 $2,770.31

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FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 4 NYC $513.61 $1,027.22 $873.14 $1,463.79

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 4 NYC $513.61 $1,027.22 $873.14 $1,463.79

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 4 NYC $514.41 $1,028.82 $874.50 $1,466.07

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 4 NYC $514.41 $1,028.82 $874.50 $1,466.07

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 4 NYC $663.00 $1,326.00 $1,127.10 $1,889.55

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 4 NYC $663.00 $1,326.00 $1,127.10 $1,889.55

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 4 NYC $663.00 $1,326.00 $1,127.10 $1,889.55FRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 4 NYC $663.00 $1,326.00 $1,127.10 $1,889.55FRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 4 NYC $663.00 $1,326.00 $1,127.10 $1,889.55FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 4 NYC $678.08 $1,356.16 $1,152.74 $1,932.53

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 4 NYC $678.08 $1,356.16 $1,152.74 $1,932.53

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 4 NYC $678.08 $1,356.16 $1,152.74 $1,932.53

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 4 NYC $678.08 $1,356.16 $1,152.74 $1,932.53

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 4 NYC $678.08 $1,356.16 $1,152.74 $1,932.53FRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 4 NYC $763.94 $1,527.88 $1,298.70 $2,177.23

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 4 NYC $763.94 $1,527.88 $1,298.70 $2,177.23FRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 4 NYC $769.93 $1,539.86 $1,308.88 $2,194.30

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 4 NYC $769.93 $1,539.86 $1,308.88 $2,194.30

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 4 NYC $884.44 $1,768.88 $1,503.55 $2,520.65

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 4 NYC $884.44 $1,768.88 $1,503.55 $2,520.65

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 4 NYC $533.41 $1,066.82 $906.80 $1,520.22

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 4 NYC $533.41 $1,066.82 $906.80 $1,520.22

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 4 NYC $523.11 $1,046.22 $889.29 $1,490.86

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 4 NYC $523.11 $1,046.22 $889.29 $1,490.86

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 4 NYC $528.66 $1,057.32 $898.72 $1,506.68

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Single + Spouse

Single + Child(ren)


FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 4 NYC $528.66 $1,057.32 $898.72 $1,506.68

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 4 NYC $673.89 $1,347.78 $1,145.61 $1,920.59

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 4 NYC $673.89 $1,347.78 $1,145.61 $1,920.59

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 4 NYC $673.89 $1,347.78 $1,145.61 $1,920.59



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 4 NYC $626.99 $1,253.98 $1,065.88 $1,786.92

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 4 NYC $626.99 $1,253.98 $1,065.88 $1,786.92




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 4 NYC $632.01 $1,264.02 $1,074.42 $1,801.23

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 4 NYC $632.01 $1,264.02 $1,074.42 $1,801.23

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 4 NYC $632.01 $1,264.02 $1,074.42 $1,801.23



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 4 NYC $750.26 $1,500.52 $1,275.44 $2,138.24

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 4 NYC $750.26 $1,500.52 $1,275.44 $2,138.24

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 4 NYC $733.16 $1,466.32 $1,246.37 $2,089.51

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 4 NYC $733.16 $1,466.32 $1,246.37 $2,089.51

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 4 NYC $876.24 $1,752.48 $1,489.61 $2,497.28

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 4 NYC $876.24 $1,752.48 $1,489.61 $2,497.28

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Single + Spouse

Single + Child(ren)


FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 4 NYC $879.89 $1,759.78 $1,495.81 $2,507.69

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 4 NYC $879.89 $1,759.78 $1,495.81 $2,507.69

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 4 NYC $303.51 $607.02 $515.97 $865.00

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 4 NYC $718.41 $1,436.82 $1,221.30 $2,047.47

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 4 NYC $718.41 $1,436.82 $1,221.30 $2,047.47

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 4 NYC $907.13 $1,814.26 $1,542.12 $2,585.32

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 4 NYC $907.13 $1,814.26 $1,542.12 $2,585.32

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 5 Rochester $367.94 $735.88 $625.50 $1,048.63

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 5 Rochester $367.94 $735.88 $625.50 $1,048.63

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 5 Rochester $368.51 $737.02 $626.47 $1,050.25

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 5 Rochester $368.51 $737.02 $626.47 $1,050.25

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 5 Rochester $474.96 $949.92 $807.43 $1,353.64

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 5 Rochester $474.96 $949.92 $807.43 $1,353.64

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 5 Rochester $474.96 $949.92 $807.43 $1,353.64FRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 5 Rochester $474.96 $949.92 $807.43 $1,353.64FRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 5 Rochester $474.96 $949.92 $807.43 $1,353.64FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 5 Rochester $485.76 $971.52 $825.79 $1,384.42

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 5 Rochester $485.76 $971.52 $825.79 $1,384.42

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 5 Rochester $485.76 $971.52 $825.79 $1,384.42

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 5 Rochester $485.76 $971.52 $825.79 $1,384.42

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 5 Rochester $485.76 $971.52 $825.79 $1,384.42FRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 5 Rochester $547.27 $1,094.54 $930.36 $1,559.72

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 5 Rochester $547.27 $1,094.54 $930.36 $1,559.72FRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 5 Rochester $551.56 $1,103.12 $937.65 $1,571.95

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Single + Spouse

Single + Child(ren)


FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 5 Rochester $551.56 $1,103.12 $937.65 $1,571.95

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 5 Rochester $633.59 $1,267.18 $1,077.10 $1,805.73

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 5 Rochester $633.59 $1,267.18 $1,077.10 $1,805.73

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 5 Rochester $382.12 $764.24 $649.60 $1,089.04

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 5 Rochester $382.12 $764.24 $649.60 $1,089.04

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 5 Rochester $374.75 $749.50 $637.08 $1,068.04

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 5 Rochester $374.75 $749.50 $637.08 $1,068.04

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 5 Rochester $378.72 $757.44 $643.82 $1,079.35

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 5 Rochester $378.72 $757.44 $643.82 $1,079.35

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 5 Rochester $482.76 $965.52 $820.69 $1,375.87

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 5 Rochester $482.76 $965.52 $820.69 $1,375.87

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 5 Rochester $482.76 $965.52 $820.69 $1,375.87



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 5 Rochester $449.16 $898.32 $763.57 $1,280.11

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 5 Rochester $449.16 $898.32 $763.57 $1,280.11




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 5 Rochester $452.76 $905.52 $769.69 $1,290.37

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 5 Rochester $452.76 $905.52 $769.69 $1,290.37

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 5 Rochester $452.76 $905.52 $769.69 $1,290.37

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FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 5 Rochester $537.47 $1,074.94 $913.70 $1,531.79

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 5 Rochester $537.47 $1,074.94 $913.70 $1,531.79

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 5 Rochester $525.22 $1,050.44 $892.87 $1,496.88

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 5 Rochester $525.22 $1,050.44 $892.87 $1,496.88

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 5 Rochester $627.72 $1,255.44 $1,067.12 $1,789.00

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 5 Rochester $627.72 $1,255.44 $1,067.12 $1,789.00

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 5 Rochester $630.33 $1,260.66 $1,071.56 $1,796.44

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 5 Rochester $630.33 $1,260.66 $1,071.56 $1,796.44

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 5 Rochester $217.43 $434.86 $369.63 $619.68

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 5 Rochester $514.66 $1,029.32 $874.92 $1,466.78

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 5 Rochester $514.66 $1,029.32 $874.92 $1,466.78

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 5 Rochester $649.85 $1,299.70 $1,104.75 $1,852.07

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 5 Rochester $649.85 $1,299.70 $1,104.75 $1,852.07

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 6 Syracuse $499.00 $998.00 $848.30 $1,422.15

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 6 Syracuse $499.00 $998.00 $848.30 $1,422.15

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 6 Syracuse $499.77 $999.54 $849.61 $1,424.34

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 6 Syracuse $499.77 $999.54 $849.61 $1,424.34

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 6 Syracuse $644.14 $1,288.28 $1,095.04 $1,835.80

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 6 Syracuse $644.14 $1,288.28 $1,095.04 $1,835.80

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 6 Syracuse $644.14 $1,288.28 $1,095.04 $1,835.80FRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 6 Syracuse $644.14 $1,288.28 $1,095.04 $1,835.80FRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 6 Syracuse $644.14 $1,288.28 $1,095.04 $1,835.80

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FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 6 Syracuse $658.79 $1,317.58 $1,119.94 $1,877.55

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 6 Syracuse $658.79 $1,317.58 $1,119.94 $1,877.55

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 6 Syracuse $658.79 $1,317.58 $1,119.94 $1,877.55

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 6 Syracuse $658.79 $1,317.58 $1,119.94 $1,877.55

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 6 Syracuse $658.79 $1,317.58 $1,119.94 $1,877.55FRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 6 Syracuse $742.21 $1,484.42 $1,261.76 $2,115.30

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 6 Syracuse $742.21 $1,484.42 $1,261.76 $2,115.30FRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 6 Syracuse $748.02 $1,496.04 $1,271.63 $2,131.86

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 6 Syracuse $748.02 $1,496.04 $1,271.63 $2,131.86

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 6 Syracuse $859.28 $1,718.56 $1,460.78 $2,448.95

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 6 Syracuse $859.28 $1,718.56 $1,460.78 $2,448.95

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 6 Syracuse $518.23 $1,036.46 $880.99 $1,476.96

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 6 Syracuse $518.23 $1,036.46 $880.99 $1,476.96

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 6 Syracuse $508.23 $1,016.46 $863.99 $1,448.46

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 6 Syracuse $508.23 $1,016.46 $863.99 $1,448.46

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 6 Syracuse $513.62 $1,027.24 $873.15 $1,463.82

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 6 Syracuse $513.62 $1,027.24 $873.15 $1,463.82

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 6 Syracuse $654.72 $1,309.44 $1,113.02 $1,865.95

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 6 Syracuse $654.72 $1,309.44 $1,113.02 $1,865.95

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 6 Syracuse $654.72 $1,309.44 $1,113.02 $1,865.95



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 6 Syracuse $609.15 $1,218.30 $1,035.56 $1,736.08

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FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 6 Syracuse $609.15 $1,218.30 $1,035.56 $1,736.08




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 6 Syracuse $614.03 $1,228.06 $1,043.85 $1,749.99

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 6 Syracuse $614.03 $1,228.06 $1,043.85 $1,749.99

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 6 Syracuse $614.03 $1,228.06 $1,043.85 $1,749.99



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 6 Syracuse $728.91 $1,457.82 $1,239.15 $2,077.39

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 6 Syracuse $728.91 $1,457.82 $1,239.15 $2,077.39

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 6 Syracuse $712.30 $1,424.60 $1,210.91 $2,030.06

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 6 Syracuse $712.30 $1,424.60 $1,210.91 $2,030.06

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 6 Syracuse $851.32 $1,702.64 $1,447.24 $2,426.26

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 6 Syracuse $851.32 $1,702.64 $1,447.24 $2,426.26

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 6 Syracuse $854.85 $1,709.70 $1,453.25 $2,436.32

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 6 Syracuse $854.85 $1,709.70 $1,453.25 $2,436.32

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 6 Syracuse $294.88 $589.76 $501.30 $840.41

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 6 Syracuse $697.98 $1,395.96 $1,186.57 $1,989.24

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 6 Syracuse $697.98 $1,395.96 $1,186.57 $1,989.24

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 6 Syracuse $881.32 $1,762.64 $1,498.24 $2,511.76

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 6 Syracuse $881.32 $1,762.64 $1,498.24 $2,511.76

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FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 7 Utica/Watertown $467.57 $935.14 $794.87 $1,332.57

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 7 Utica/Watertown $467.57 $935.14 $794.87 $1,332.57

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 7 Utica/Watertown $468.29 $936.58 $796.09 $1,334.63

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 7 Utica/Watertown $468.29 $936.58 $796.09 $1,334.63

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 7 Utica/Watertown $603.56 $1,207.12 $1,026.05 $1,720.15

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 7 Utica/Watertown $603.56 $1,207.12 $1,026.05 $1,720.15

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 7 Utica/Watertown $603.56 $1,207.12 $1,026.05 $1,720.15



FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 7 Utica/Watertown $617.28 $1,234.56 $1,049.38 $1,759.25

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 7 Utica/Watertown $617.28 $1,234.56 $1,049.38 $1,759.25

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 7 Utica/Watertown $617.28 $1,234.56 $1,049.38 $1,759.25



FRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 7 Utica/Watertown $695.45 $1,390.90 $1,182.27 $1,982.03

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 7 Utica/Watertown $695.45 $1,390.90 $1,182.27 $1,982.03

FRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 7 Utica/Watertown $700.90 $1,401.80 $1,191.53 $1,997.57

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 7 Utica/Watertown $700.90 $1,401.80 $1,191.53 $1,997.57

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 7 Utica/Watertown $805.14 $1,610.28 $1,368.74 $2,294.65

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FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 7 Utica/Watertown $805.14 $1,610.28 $1,368.74 $2,294.65

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 7 Utica/Watertown $485.58 $971.16 $825.49 $1,383.90

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 7 Utica/Watertown $485.58 $971.16 $825.49 $1,383.90

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 7 Utica/Watertown $476.21 $952.42 $809.56 $1,357.20

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 7 Utica/Watertown $476.21 $952.42 $809.56 $1,357.20

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 7 Utica/Watertown $481.26 $962.52 $818.14 $1,371.59

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 7 Utica/Watertown $481.26 $962.52 $818.14 $1,371.59

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 7 Utica/Watertown $613.47 $1,226.94 $1,042.90 $1,748.39

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 7 Utica/Watertown $613.47 $1,226.94 $1,042.90 $1,748.39

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 7 Utica/Watertown $613.47 $1,226.94 $1,042.90 $1,748.39



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 7 Utica/Watertown $570.77 $1,141.54 $970.31 $1,626.69

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 7 Utica/Watertown $570.77 $1,141.54 $970.31 $1,626.69

FRNY-HMO-DS1-002-N-73 (2018)Non-Standard Silver 2 CSR AV73 Individual Non-Standard Silver 7 Utica/Watertown $570.77 $1,141.54 $970.31 $1,626.69



FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 7 Utica/Watertown $575.35 $1,150.70 $978.10 $1,639.75

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 7 Utica/Watertown $575.35 $1,150.70 $978.10 $1,639.75

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FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 7 Utica/Watertown $575.35 $1,150.70 $978.10 $1,639.75



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 7 Utica/Watertown $682.99 $1,365.98 $1,161.08 $1,946.52

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 7 Utica/Watertown $682.99 $1,365.98 $1,161.08 $1,946.52

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 7 Utica/Watertown $667.42 $1,334.84 $1,134.61 $1,902.15

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 7 Utica/Watertown $667.42 $1,334.84 $1,134.61 $1,902.15

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 7 Utica/Watertown $797.68 $1,595.36 $1,356.06 $2,273.39

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 7 Utica/Watertown $797.68 $1,595.36 $1,356.06 $2,273.39

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 7 Utica/Watertown $801.00 $1,602.00 $1,361.70 $2,282.85

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 7 Utica/Watertown $801.00 $1,602.00 $1,361.70 $2,282.85

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 7 Utica/Watertown $276.30 $552.60 $469.71 $787.46

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 7 Utica/Watertown $654.00 $1,308.00 $1,111.80 $1,863.90

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 7 Utica/Watertown $654.00 $1,308.00 $1,111.80 $1,863.90

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 7 Utica/Watertown $825.80 $1,651.60 $1,403.86 $2,353.53

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 7 Utica/Watertown $825.80 $1,651.60 $1,403.86 $2,353.53

FRNY-X-100 Dependent Through Age 29 IndividualStandard & Non-Standard

All Metal Levels excluding "Catastrophic" 1 Albany 1.00% 1.00% 1.00% 1.00%


All Metal Levels excluding "Catastrophic" 2 Buffalo 1.00% 1.00% 1.00% 1.00%

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All Metal Levels excluding "Catastrophic" 3 Mid-Hudson 1.00% 1.00% 1.00% 1.00%


All Metal Levels excluding "Catastrophic" 4 NYC 1.00% 1.00% 1.00% 1.00%


All Metal Levels excluding "Catastrophic" 5 Rochester 1.00% 1.00% 1.00% 1.00%


All Metal Levels excluding "Catastrophic" 6 Syracuse 1.00% 1.00% 1.00% 1.00%


All Metal Levels excluding "Catastrophic" 7 Utica/Watertown 1.00% 1.00% 1.00% 1.00%

NY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 1 Albany $428.16 $856.32 $727.87 $1,220.26NY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 1 Albany $428.82 $857.64 $728.99 $1,222.14NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 1 Albany $552.69 $1,105.38 $939.57 $1,575.17NY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 1 Albany $565.26 $1,130.52 $960.94 $1,610.99NY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 1 Albany $636.84 $1,273.68 $1,082.63 $1,814.99NY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 1 Albany $641.83 $1,283.66 $1,091.11 $1,829.22NY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 1 Albany $737.29 $1,474.58 $1,253.39 $2,101.28NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 1 Albany $444.66 $889.32 $755.92 $1,267.28NY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 1 Albany $436.08 $872.16 $741.34 $1,242.83NY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 1 Albany $440.70 $881.40 $749.19 $1,256.00NY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 1 Albany $455.88 $911.76 $775.00 $1,299.26NY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 1 Albany $470.40 $940.80 $799.68 $1,340.64

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 1 Albany $484.58 $969.16 $823.79 $1,381.05

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 1 Albany $561.77 $1,123.54 $955.01 $1,601.04NY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 1 Albany $522.67 $1,045.34 $888.54 $1,489.61NY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 1 Albany $526.86 $1,053.72 $895.66 $1,501.55NY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 1 Albany $526.86 $1,053.72 $895.66 $1,501.55

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 1 Albany $559.78 $1,119.56 $951.63 $1,595.37NY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 1 Albany $625.43 $1,250.86 $1,063.23 $1,782.48NY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 1 Albany $611.17 $1,222.34 $1,038.99 $1,741.83

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NY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 1 Albany $648.24 $1,296.48 $1,102.01 $1,847.48NY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 1 Albany $633.27 $1,266.54 $1,076.56 $1,804.82NY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 1 Albany $605.47 $1,210.94 $1,029.30 $1,725.59NY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 1 Albany $586.94 $1,173.88 $997.80 $1,672.78

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 1 Albany $598.88 $1,197.76 $1,018.10 $1,706.81

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 1 Albany $854.58 $1,709.16 $1,452.79 $2,435.55NY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 1 Albany $253.02 $506.04 $430.13 $721.11NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 1 Albany $730.46 $1,460.92 $1,241.78 $2,081.81NY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 1 Albany $733.49 $1,466.98 $1,246.93 $2,090.45

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 1 Albany $756.20 $1,512.40 $1,285.54 $2,155.17

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 1 Albany N/A N/A N/A N/ANY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 1 Albany N/A N/A N/A N/ANY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 1 Albany N/A N/A N/A N/ANY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 1 Albany N/A N/A N/A N/ANY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 1 Albany N/A N/A N/A N/ANY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 1 Albany N/A N/A N/A N/ANY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 1 Albany N/A N/A N/A N/ANY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 2 Buffalo $396.72 $793.44 $674.42 $1,130.65NY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 2 Buffalo $397.33 $794.66 $675.46 $1,132.39NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 2 Buffalo $512.11 $1,024.22 $870.59 $1,459.51NY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 2 Buffalo $523.76 $1,047.52 $890.39 $1,492.72NY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 2 Buffalo $590.08 $1,180.16 $1,003.14 $1,681.73NY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 2 Buffalo $594.70 $1,189.40 $1,010.99 $1,694.90NY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 2 Buffalo $683.15 $1,366.30 $1,161.36 $1,946.98NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 2 Buffalo $412.01 $824.02 $700.42 $1,174.23NY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 2 Buffalo $404.06 $808.12 $686.90 $1,151.57NY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 2 Buffalo $408.34 $816.68 $694.18 $1,163.77NY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 2 Buffalo $422.41 $844.82 $718.10 $1,203.87NY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 2 Buffalo $435.86 $871.72 $740.96 $1,242.20

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 2 Buffalo $449.00 $898.00 $763.30 $1,279.65

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 2 Buffalo $520.52 $1,041.04 $884.88 $1,483.48NY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 2 Buffalo $484.29 $968.58 $823.29 $1,380.23NY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 2 Buffalo $488.17 $976.34 $829.89 $1,391.28

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NY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 2 Buffalo $488.17 $976.34 $829.89 $1,391.28

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 2 Buffalo $518.68 $1,037.36 $881.76 $1,478.24NY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 2 Buffalo $579.51 $1,159.02 $985.17 $1,651.60NY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 2 Buffalo $566.30 $1,132.60 $962.71 $1,613.96NY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 2 Buffalo $600.65 $1,201.30 $1,021.11 $1,711.85NY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 2 Buffalo $586.77 $1,173.54 $997.51 $1,672.29NY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 2 Buffalo $561.02 $1,122.04 $953.73 $1,598.91NY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 2 Buffalo $543.84 $1,087.68 $924.53 $1,549.94

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 2 Buffalo $554.91 $1,109.82 $943.35 $1,581.49

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 2 Buffalo $791.84 $1,583.68 $1,346.13 $2,256.74NY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 2 Buffalo $234.44 $468.88 $398.55 $668.15NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 2 Buffalo $676.82 $1,353.64 $1,150.59 $1,928.94NY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 2 Buffalo $679.64 $1,359.28 $1,155.39 $1,936.97

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 2 Buffalo $700.68 $1,401.36 $1,191.16 $1,996.94

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 2 Buffalo N/A N/A N/A N/ANY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 2 Buffalo N/A N/A N/A N/ANY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 2 Buffalo N/A N/A N/A N/ANY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 2 Buffalo N/A N/A N/A N/ANY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 2 Buffalo N/A N/A N/A N/ANY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 2 Buffalo N/A N/A N/A N/ANY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 2 Buffalo N/A N/A N/A N/ANY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 3 Mid-Hudson $550.36 $1,100.72 $935.61 $1,568.53NY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 3 Mid-Hudson $551.21 $1,102.42 $937.06 $1,570.95NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 3 Mid-Hudson $710.44 $1,420.88 $1,207.75 $2,024.75NY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 3 Mid-Hudson $726.59 $1,453.18 $1,235.20 $2,070.78NY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 3 Mid-Hudson $818.60 $1,637.20 $1,391.62 $2,333.01NY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 3 Mid-Hudson $825.01 $1,650.02 $1,402.52 $2,351.28NY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 3 Mid-Hudson $947.72 $1,895.44 $1,611.12 $2,701.00NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 3 Mid-Hudson $571.57 $1,143.14 $971.67 $1,628.97NY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 3 Mid-Hudson $560.54 $1,121.08 $952.92 $1,597.54NY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 3 Mid-Hudson $566.48 $1,132.96 $963.02 $1,614.47NY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 3 Mid-Hudson $586.00 $1,172.00 $996.20 $1,670.10NY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 3 Mid-Hudson $604.66 $1,209.32 $1,027.92 $1,723.28

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NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 3 Mid-Hudson $622.89 $1,245.78 $1,058.91 $1,775.24

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 3 Mid-Hudson $722.11 $1,444.22 $1,227.59 $2,058.01NY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 3 Mid-Hudson $671.85 $1,343.70 $1,142.15 $1,914.77NY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 3 Mid-Hudson $677.23 $1,354.46 $1,151.29 $1,930.11NY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 3 Mid-Hudson $677.23 $1,354.46 $1,151.29 $1,930.11

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 3 Mid-Hudson $719.56 $1,439.12 $1,223.25 $2,050.75NY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 3 Mid-Hudson $803.94 $1,607.88 $1,366.70 $2,291.23NY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 3 Mid-Hudson $785.61 $1,571.22 $1,335.54 $2,238.99NY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 3 Mid-Hudson $833.26 $1,666.52 $1,416.54 $2,374.79NY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 3 Mid-Hudson $814.02 $1,628.04 $1,383.83 $2,319.96NY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 3 Mid-Hudson $778.28 $1,556.56 $1,323.08 $2,218.10NY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 3 Mid-Hudson $754.46 $1,508.92 $1,282.58 $2,150.21

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 3 Mid-Hudson $769.82 $1,539.64 $1,308.69 $2,193.99

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 3 Mid-Hudson $1,098.49 $2,196.98 $1,867.43 $3,130.70NY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 3 Mid-Hudson $325.23 $650.46 $552.89 $926.91NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 3 Mid-Hudson $938.94 $1,877.88 $1,596.20 $2,675.98NY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 3 Mid-Hudson $942.84 $1,885.68 $1,602.83 $2,687.09

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 3 Mid-Hudson $972.04 $1,944.08 $1,652.47 $2,770.31

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 3 Mid-Hudson N/A N/A N/A N/ANY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 3 Mid-Hudson N/A N/A N/A N/ANY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 3 Mid-Hudson N/A N/A N/A N/ANY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 3 Mid-Hudson N/A N/A N/A N/ANY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 3 Mid-Hudson N/A N/A N/A N/ANY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 3 Mid-Hudson N/A N/A N/A N/ANY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 3 Mid-Hudson N/A N/A N/A N/ANY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 4 NYC $513.61 $1,027.22 $873.14 $1,463.79NY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 4 NYC $514.41 $1,028.82 $874.50 $1,466.07NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 4 NYC $663.00 $1,326.00 $1,127.10 $1,889.55NY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 4 NYC $678.08 $1,356.16 $1,152.74 $1,932.53NY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 4 NYC $763.94 $1,527.88 $1,298.70 $2,177.23NY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 4 NYC $769.93 $1,539.86 $1,308.88 $2,194.30NY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 4 NYC $884.44 $1,768.88 $1,503.55 $2,520.65

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NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 4 NYC $533.41 $1,066.82 $906.80 $1,520.22NY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 4 NYC $523.11 $1,046.22 $889.29 $1,490.86NY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 4 NYC $528.66 $1,057.32 $898.72 $1,506.68NY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 4 NYC $546.87 $1,093.74 $929.68 $1,558.58NY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 4 NYC $564.29 $1,128.58 $959.29 $1,608.23

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 4 NYC $581.29 $1,162.58 $988.19 $1,656.68

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 4 NYC $673.89 $1,347.78 $1,145.61 $1,920.59NY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 4 NYC $626.99 $1,253.98 $1,065.88 $1,786.92NY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 4 NYC $632.01 $1,264.02 $1,074.42 $1,801.23NY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 4 NYC $632.01 $1,264.02 $1,074.42 $1,801.23

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 4 NYC $671.51 $1,343.02 $1,141.57 $1,913.80NY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 4 NYC $750.26 $1,500.52 $1,275.44 $2,138.24NY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 4 NYC $733.16 $1,466.32 $1,246.37 $2,089.51NY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 4 NYC $777.62 $1,555.24 $1,321.95 $2,216.22NY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 4 NYC $759.66 $1,519.32 $1,291.42 $2,165.03NY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 4 NYC $726.31 $1,452.62 $1,234.73 $2,069.98NY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 4 NYC $704.08 $1,408.16 $1,196.94 $2,006.63

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 4 NYC $718.41 $1,436.82 $1,221.30 $2,047.47

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 4 NYC $1,025.14 $2,050.28 $1,742.74 $2,921.65NY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 4 NYC $303.51 $607.02 $515.97 $865.00NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 4 NYC $876.24 $1,752.48 $1,489.61 $2,497.28NY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 4 NYC $879.89 $1,759.78 $1,495.81 $2,507.69

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 4 NYC $907.13 $1,814.26 $1,542.12 $2,585.32

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 4 NYC N/A N/A N/A N/ANY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 4 NYC N/A N/A N/A N/ANY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 4 NYC N/A N/A N/A N/ANY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 4 NYC N/A N/A N/A N/ANY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 4 NYC N/A N/A N/A N/ANY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 4 NYC N/A N/A N/A N/ANY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 4 NYC N/A N/A N/A N/ANY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 5 Rochester $367.94 $735.88 $625.50 $1,048.63NY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 5 Rochester $368.51 $737.02 $626.47 $1,050.25

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NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 5 Rochester $474.96 $949.92 $807.43 $1,353.64NY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 5 Rochester $485.76 $971.52 $825.79 $1,384.42NY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 5 Rochester $547.27 $1,094.54 $930.36 $1,559.72NY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 5 Rochester $551.56 $1,103.12 $937.65 $1,571.95NY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 5 Rochester $633.59 $1,267.18 $1,077.10 $1,805.73NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 5 Rochester $382.12 $764.24 $649.60 $1,089.04NY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 5 Rochester $374.75 $749.50 $637.08 $1,068.04NY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 5 Rochester $378.72 $757.44 $643.82 $1,079.35NY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 5 Rochester $391.76 $783.52 $665.99 $1,116.52NY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 5 Rochester $404.24 $808.48 $687.21 $1,152.08

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 5 Rochester $416.43 $832.86 $707.93 $1,186.83

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 5 Rochester $482.76 $965.52 $820.69 $1,375.87NY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 5 Rochester $449.16 $898.32 $763.57 $1,280.11NY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 5 Rochester $452.76 $905.52 $769.69 $1,290.37NY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 5 Rochester $452.76 $905.52 $769.69 $1,290.37

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 5 Rochester $481.06 $962.12 $817.80 $1,371.02NY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 5 Rochester $537.47 $1,074.94 $913.70 $1,531.79NY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 5 Rochester $525.22 $1,050.44 $892.87 $1,496.88NY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 5 Rochester $557.07 $1,114.14 $947.02 $1,587.65NY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 5 Rochester $544.21 $1,088.42 $925.16 $1,551.00NY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 5 Rochester $520.32 $1,040.64 $884.54 $1,482.91NY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 5 Rochester $504.39 $1,008.78 $857.46 $1,437.51

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 5 Rochester $514.66 $1,029.32 $874.92 $1,466.78

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 5 Rochester $734.39 $1,468.78 $1,248.46 $2,093.01NY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 5 Rochester $217.43 $434.86 $369.63 $619.68NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 5 Rochester $627.72 $1,255.44 $1,067.12 $1,789.00NY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 5 Rochester $630.33 $1,260.66 $1,071.56 $1,796.44

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 5 Rochester $649.85 $1,299.70 $1,104.75 $1,852.07

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 5 Rochester N/A N/A N/A N/ANY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 5 Rochester N/A N/A N/A N/ANY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 5 Rochester N/A N/A N/A N/ANY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 5 Rochester N/A N/A N/A N/A

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NY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 5 Rochester N/A N/A N/A N/ANY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 5 Rochester N/A N/A N/A N/ANY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 5 Rochester N/A N/A N/A N/ANY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 6 Syracuse $499.00 $998.00 $848.30 $1,422.15NY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 6 Syracuse $499.77 $999.54 $849.61 $1,424.34NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 6 Syracuse $644.14 $1,288.28 $1,095.04 $1,835.80NY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 6 Syracuse $658.79 $1,317.58 $1,119.94 $1,877.55NY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 6 Syracuse $742.21 $1,484.42 $1,261.76 $2,115.30NY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 6 Syracuse $748.02 $1,496.04 $1,271.63 $2,131.86NY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 6 Syracuse $859.28 $1,718.56 $1,460.78 $2,448.95NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 6 Syracuse $518.23 $1,036.46 $880.99 $1,476.96NY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 6 Syracuse $508.23 $1,016.46 $863.99 $1,448.46NY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 6 Syracuse $513.62 $1,027.24 $873.15 $1,463.82NY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 6 Syracuse $531.31 $1,062.62 $903.23 $1,514.23NY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 6 Syracuse $548.23 $1,096.46 $931.99 $1,562.46

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 6 Syracuse $564.76 $1,129.52 $960.09 $1,609.57

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 6 Syracuse $654.72 $1,309.44 $1,113.02 $1,865.95NY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 6 Syracuse $609.15 $1,218.30 $1,035.56 $1,736.08NY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 6 Syracuse $614.03 $1,228.06 $1,043.85 $1,749.99NY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 6 Syracuse $614.03 $1,228.06 $1,043.85 $1,749.99

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 6 Syracuse $652.41 $1,304.82 $1,109.10 $1,859.37NY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 6 Syracuse $728.91 $1,457.82 $1,239.15 $2,077.39NY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 6 Syracuse $712.30 $1,424.60 $1,210.91 $2,030.06NY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 6 Syracuse $755.50 $1,511.00 $1,284.35 $2,153.18NY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 6 Syracuse $738.05 $1,476.10 $1,254.69 $2,103.44NY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 6 Syracuse $705.65 $1,411.30 $1,199.61 $2,011.10NY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 6 Syracuse $684.05 $1,368.10 $1,162.89 $1,949.54

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 6 Syracuse $697.98 $1,395.96 $1,186.57 $1,989.24

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 6 Syracuse $995.98 $1,991.96 $1,693.17 $2,838.54NY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 6 Syracuse $294.88 $589.76 $501.30 $840.41NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 6 Syracuse $851.32 $1,702.64 $1,447.24 $2,426.26NY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 6 Syracuse $854.85 $1,709.70 $1,453.25 $2,436.32

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NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 6 Syracuse $881.32 $1,762.64 $1,498.24 $2,511.76

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 6 Syracuse N/A N/A N/A N/ANY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 6 Syracuse N/A N/A N/A N/ANY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 6 Syracuse N/A N/A N/A N/ANY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 6 Syracuse N/A N/A N/A N/ANY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 6 Syracuse N/A N/A N/A N/ANY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 6 Syracuse N/A N/A N/A N/ANY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 6 Syracuse N/A N/A N/A N/A

NY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 7 Utica/Watertown $467.57 $935.14 $794.87 $1,332.57

NY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 7 Utica/Watertown $468.29 $936.58 $796.09 $1,334.63

NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 7 Utica/Watertown $603.56 $1,207.12 $1,026.05 $1,720.15

NY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 7 Utica/Watertown $617.28 $1,234.56 $1,049.38 $1,759.25

NY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 7 Utica/Watertown $695.45 $1,390.90 $1,182.27 $1,982.03

NY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 7 Utica/Watertown $700.90 $1,401.80 $1,191.53 $1,997.57

NY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 7 Utica/Watertown $805.14 $1,610.28 $1,368.74 $2,294.65

NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 7 Utica/Watertown $485.58 $971.16 $825.49 $1,383.90

NY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 7 Utica/Watertown $476.21 $952.42 $809.56 $1,357.20

NY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 7 Utica/Watertown $481.26 $962.52 $818.14 $1,371.59

NY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 7 Utica/Watertown $497.84 $995.68 $846.33 $1,418.84

NY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 7 Utica/Watertown $513.70 $1,027.40 $873.29 $1,464.05

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 7 Utica/Watertown $529.18 $1,058.36 $899.61 $1,508.16

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 7 Utica/Watertown $613.47 $1,226.94 $1,042.90 $1,748.39

Page 66


2018



Single + Spouse

Single + Child(ren)


NY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 7 Utica/Watertown $570.77 $1,141.54 $970.31 $1,626.69

NY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 7 Utica/Watertown $575.35 $1,150.70 $978.10 $1,639.75

NY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 7 Utica/Watertown $575.35 $1,150.70 $978.10 $1,639.75

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 7 Utica/Watertown $611.31 $1,222.62 $1,039.23 $1,742.23

NY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 7 Utica/Watertown $682.99 $1,365.98 $1,161.08 $1,946.52

NY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 7 Utica/Watertown $667.42 $1,334.84 $1,134.61 $1,902.15





NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 7 Utica/Watertown $654.00 $1,308.00 $1,111.80 $1,863.90

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 7 Utica/Watertown $933.23 $1,866.46 $1,586.49 $2,659.71

NY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 7 Utica/Watertown $276.30 $552.60 $469.71 $787.46

NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 7 Utica/Watertown $797.68 $1,595.36 $1,356.06 $2,273.39

NY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 7 Utica/Watertown $801.00 $1,602.00 $1,361.70 $2,282.85

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 7 Utica/Watertown $825.80 $1,651.60 $1,403.86 $2,353.53

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 7 Utica/Watertown N/A N/A N/A N/A

NY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 7 Utica/Watertown N/A N/A N/A N/A

NY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 7 Utica/Watertown N/A N/A N/A N/A

Page 67


2018



Single + Spouse

Single + Child(ren)


NY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 7 Utica/Watertown N/A N/A N/A N/A

NY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 7 Utica/Watertown N/A N/A N/A N/A

NY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 7 Utica/Watertown N/A N/A N/A N/A

NY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 7 Utica/Watertown N/A N/A N/A N/A

NY-X-100 Dependent Through Age 29 IndividualStandard & Non-Standard














NY-X-USNFUnlimited Skilled Nursing Facility Individual

Standard & Non-Standard








Page 68


2018



Single + Spouse

Single + Child(ren)














Page 69

MVP Health Plan, Inc.PremiumsEffective January 1, 2018Version 8/16/2017


Standard vs Non-Standard Metal Level Rate Region

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 1 Albany

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 1 Albany

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 1 Albany

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 1 Albany

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 1 Albany

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 1 Albany

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 1 AlbanyFRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 1 AlbanyFRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 1 AlbanyFRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 1 Albany

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 1 Albany

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 1 Albany

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 1 Albany

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 1 AlbanyFRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 1 Albany

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 1 AlbanyFRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 1 Albany

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 1 Albany

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 1 Albany

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 1 Albany

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 1 Albany

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 1 Albany

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 1 Albany

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 1 Albany

Exhibit C

2018

Child Only(1 Child)

Child Only(2 Children)

Child Only(3+ Children)

$176.40 $352.80 $529.20

$176.40 $352.80 $529.20$176.67 $353.34 $530.01

$176.67 $353.34 $530.01$227.71 $455.42 $683.13

$227.71 $455.42 $683.13$227.71 $455.42 $683.13$227.71 $455.42 $683.13$227.71 $455.42 $683.13$232.89 $465.78 $698.67

$232.89 $465.78 $698.67

$232.89 $465.78 $698.67

$232.89 $465.78 $698.67

$232.89 $465.78 $698.67$262.38 $524.76 $787.14

$262.38 $524.76 $787.14$264.43 $528.86 $793.29

$264.43 $528.86 $793.29$303.76 $607.52 $911.28

$303.76 $607.52 $911.28N/A N/A N/A

N/A N/A N/AN/A N/A N/A

N/A N/A N/A

Page 70




FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 1 Albany

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 1 Albany

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 1 Albany

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 1 Albany

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 1 Albany



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 1 Albany

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 1 Albany




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 1 Albany

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 1 Albany

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 1 Albany



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 1 Albany

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 1 Albany

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 1 Albany

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 1 Albany

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 1 Albany

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A




Page 71




FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 1 Albany

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 1 Albany

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 1 Albany

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 1 Albany

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 1 Albany

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 1 Albany

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 1 Albany

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 1 Albany

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 2 Buffalo

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 2 Buffalo

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 2 Buffalo

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 2 Buffalo

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 2 Buffalo

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 2 Buffalo

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 2 BuffaloFRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 2 BuffaloFRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 2 BuffaloFRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 2 Buffalo

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 2 Buffalo

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 2 Buffalo

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 2 Buffalo

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 2 BuffaloFRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 2 BuffaloFRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 2 Buffalo

Exhibit C

2018

Child Only(1 Child)





N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A$163.45 $326.90 $490.35

$163.45 $326.90 $490.35$163.70 $327.40 $491.10

$163.70 $327.40 $491.10$210.99 $421.98 $632.97

$210.99 $421.98 $632.97$210.99 $421.98 $632.97$210.99 $421.98 $632.97$210.99 $421.98 $632.97$215.79 $431.58 $647.37

$215.79 $431.58 $647.37

$215.79 $431.58 $647.37

$215.79 $431.58 $647.37

$215.79 $431.58 $647.37$243.11 $486.22 $729.33$245.02 $490.04 $735.06

Page 72




FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 2 Buffalo

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 2 BuffaloFRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 2 Buffalo

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 2 Buffalo

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 2 Buffalo

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 2 Buffalo

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 2 Buffalo

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 2 Buffalo

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 2 Buffalo

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 2 Buffalo

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 2 Buffalo

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 2 Buffalo

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 2 Buffalo



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 2 Buffalo

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 2 Buffalo




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 2 Buffalo

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 2 Buffalo

Exhibit C

2018

Child Only(1 Child)



$245.02 $490.04 $735.06

$243.11 $486.22 $729.33$281.46 $562.92 $844.38

$281.46 $562.92 $844.38N/A N/A N/A




N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

Page 73




FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 2 Buffalo



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 2 Buffalo

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 2 Buffalo

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 2 Buffalo

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 2 Buffalo

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 2 Buffalo

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 2 Buffalo

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 2 Buffalo

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 2 Buffalo

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 2 Buffalo

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 2 Buffalo

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 2 Buffalo

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 2 Buffalo

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 2 Buffalo

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 3 Mid-Hudson

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 3 Mid-Hudson

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 3 Mid-Hudson

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 3 Mid-Hudson

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 3 Mid-Hudson

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 3 Mid-Hudson

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 3 Mid-HudsonFRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 3 Mid-Hudson

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A

N/A N/A N/A






N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A$226.75 $453.50 $680.25

$226.75 $453.50 $680.25$227.10 $454.20 $681.30

$227.10 $454.20 $681.30$292.70 $585.40 $878.10

$292.70 $585.40 $878.10$292.70 $585.40 $878.10$292.70 $585.40 $878.10

Page 74




FRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 3 Mid-HudsonFRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 3 Mid-Hudson

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 3 Mid-Hudson

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 3 Mid-Hudson

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 3 Mid-Hudson

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 3 Mid-HudsonFRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 3 Mid-Hudson

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 3 Mid-HudsonFRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 3 Mid-Hudson

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 3 Mid-Hudson

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 3 Mid-Hudson

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 3 Mid-Hudson

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 3 Mid-Hudson

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 3 Mid-Hudson

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 3 Mid-Hudson

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 3 Mid-Hudson

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 3 Mid-Hudson

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 3 Mid-Hudson

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 3 Mid-Hudson

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 3 Mid-Hudson

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 3 Mid-Hudson



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 3 Mid-Hudson

Exhibit C

2018

Child Only(1 Child)



$292.70 $585.40 $878.10$299.36 $598.72 $898.08

$299.36 $598.72 $898.08

$299.36 $598.72 $898.08

$299.36 $598.72 $898.08

$299.36 $598.72 $898.08$337.26 $674.52 $1,011.78

$337.26 $674.52 $1,011.78$339.91 $679.82 $1,019.73

$339.91 $679.82 $1,019.73$390.46 $780.92 $1,171.38

$390.46 $780.92 $1,171.38N/A N/A N/A




N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


Page 75




FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 3 Mid-Hudson




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 3 Mid-Hudson

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 3 Mid-Hudson

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 3 Mid-Hudson



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 3 Mid-Hudson

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 3 Mid-Hudson

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 3 Mid-Hudson

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 3 Mid-Hudson

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 3 Mid-Hudson

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 3 Mid-Hudson

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 3 Mid-Hudson

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 3 Mid-Hudson

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 3 Mid-Hudson

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 3 Mid-Hudson

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 3 Mid-Hudson

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 3 Mid-Hudson

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 3 Mid-Hudson

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A






N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

Page 76




FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 4 NYC

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 4 NYC

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 4 NYC

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 4 NYC

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 4 NYC

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 4 NYC

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 4 NYCFRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 4 NYCFRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 4 NYCFRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 4 NYC

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 4 NYC

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 4 NYC

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 4 NYC

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 4 NYCFRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 4 NYC

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 4 NYCFRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 4 NYC

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 4 NYC

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 4 NYC

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 4 NYC

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 4 NYC

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 4 NYC

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 4 NYC

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 4 NYC

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 4 NYC

Exhibit C

2018

Child Only(1 Child)



$211.61 $423.22 $634.83

$211.61 $423.22 $634.83$211.93 $423.86 $635.79

$211.93 $423.86 $635.79$273.16 $546.32 $819.48

$273.16 $546.32 $819.48$273.16 $546.32 $819.48$273.16 $546.32 $819.48$273.16 $546.32 $819.48$279.37 $558.74 $838.11

$279.37 $558.74 $838.11

$279.37 $558.74 $838.11

$279.37 $558.74 $838.11

$279.37 $558.74 $838.11$314.74 $629.48 $944.22

$314.74 $629.48 $944.22$317.21 $634.42 $951.63

$317.21 $634.42 $951.63$364.39 $728.78 $1,093.17

$364.39 $728.78 $1,093.17N/A N/A N/A



Page 77




FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 4 NYC

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 4 NYC

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 4 NYC

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 4 NYC



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 4 NYC

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 4 NYC




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 4 NYC

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 4 NYC

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 4 NYC



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 4 NYC

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 4 NYC

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 4 NYC

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 4 NYC

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 4 NYC

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 4 NYC

Exhibit C

2018

Child Only(1 Child)




N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A




N/A N/A N/A

Page 78




FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 4 NYC

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 4 NYC

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 4 NYC

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 4 NYC

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 4 NYC

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 4 NYC

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 4 NYC

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 5 Rochester

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 5 Rochester

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 5 Rochester

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 5 Rochester

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 5 Rochester

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 5 Rochester

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 5 RochesterFRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 5 RochesterFRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 5 RochesterFRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 5 Rochester

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 5 Rochester

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 5 Rochester

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 5 Rochester

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 5 RochesterFRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 5 Rochester

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 5 RochesterFRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 5 Rochester

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A$151.59 $303.18 $454.77

$151.59 $303.18 $454.77$151.83 $303.66 $455.49

$151.83 $303.66 $455.49$195.68 $391.36 $587.04

$195.68 $391.36 $587.04$195.68 $391.36 $587.04$195.68 $391.36 $587.04$195.68 $391.36 $587.04$200.13 $400.26 $600.39

$200.13 $400.26 $600.39

$200.13 $400.26 $600.39

$200.13 $400.26 $600.39

$200.13 $400.26 $600.39$225.48 $450.96 $676.44

$225.48 $450.96 $676.44$227.24 $454.48 $681.72

Page 79




FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 5 Rochester

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 5 Rochester

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 5 Rochester

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 5 Rochester

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 5 Rochester

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 5 Rochester

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 5 Rochester

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 5 Rochester

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 5 Rochester

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 5 Rochester

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 5 Rochester

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 5 Rochester



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 5 Rochester

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 5 Rochester




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 5 Rochester

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 5 Rochester

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 5 Rochester

Exhibit C

2018

Child Only(1 Child)



$227.24 $454.48 $681.72$261.04 $522.08 $783.12

$261.04 $522.08 $783.12N/A N/A N/A




N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

Page 80






FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 5 Rochester

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 5 Rochester

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 5 Rochester

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 5 Rochester

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 5 Rochester

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 5 Rochester

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 5 Rochester

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 5 Rochester

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 5 Rochester

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 5 Rochester

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 5 Rochester

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 5 Rochester

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 5 Rochester

FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 6 Syracuse

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 6 Syracuse

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 6 Syracuse

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 6 Syracuse

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 6 Syracuse

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 6 Syracuse

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 6 SyracuseFRNY-HMO-DS1-001-S-87 (2018) Standard Silver CSR AV87 Individual Standard Silver 6 SyracuseFRNY-HMO-DS1-001-S-94 (2018) Standard Silver CSR AV94 Individual Standard Silver 6 Syracuse

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A






N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A$205.59 $411.18 $616.77

$205.59 $411.18 $616.77$205.91 $411.82 $617.73

$205.91 $411.82 $617.73$265.39 $530.78 $796.17

$265.39 $530.78 $796.17$265.39 $530.78 $796.17$265.39 $530.78 $796.17$265.39 $530.78 $796.17

Page 81




FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 6 Syracuse

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 6 Syracuse

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 6 Syracuse

FRNY-HMO-DS1-002-S-87 (2018) Standard Silver 2 CSR AV87 Individual Standard Silver 6 Syracuse

FRNY-HMO-DS1-002-S-94 (2018) Standard Silver 2 CSR AV94 Individual Standard Silver 6 SyracuseFRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 6 Syracuse

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 6 SyracuseFRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 6 Syracuse

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 6 Syracuse

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 6 Syracuse

FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 6 Syracuse

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 6 Syracuse

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 6 Syracuse

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 6 Syracuse

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 6 Syracuse

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 6 Syracuse

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 6 Syracuse

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 6 Syracuse

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 6 Syracuse

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 6 Syracuse



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 6 Syracuse

Exhibit C

2018

Child Only(1 Child)



$271.42 $542.84 $814.26

$271.42 $542.84 $814.26

$271.42 $542.84 $814.26

$271.42 $542.84 $814.26

$271.42 $542.84 $814.26$305.79 $611.58 $917.37

$305.79 $611.58 $917.37$308.19 $616.38 $924.57

$308.19 $616.38 $924.57$354.02 $708.04 $1,062.06

$354.02 $708.04 $1,062.06N/A N/A N/A




N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


Page 82




FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 6 Syracuse




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 6 Syracuse

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 6 Syracuse

FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 6 Syracuse



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 6 Syracuse

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 6 Syracuse

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 6 Syracuse

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 6 Syracuse

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 6 Syracuse

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 6 Syracuse

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 6 Syracuse

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 6 Syracuse

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 6 Syracuse

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 6 Syracuse

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 6 Syracuse

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 6 Syracuse

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 6 Syracuse

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A

N/A N/A N/A

N/A N/A N/A


N/A N/A N/A

N/A N/A N/A

N/A N/A N/A






N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

Page 83




FRNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 7 Utica/Watertown

FRNY-HMOH-DBA1-001-S (2018)Standard Bronze AI/NA Variation Individual Standard Bronze 7 Utica/Watertown

FRNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 7 Utica/Watertown

FRNY-HMO-DBA1-002-S (2018)Standard Bronze 2 AI/NA Variation Individual Standard Bronze 7 Utica/Watertown

FRNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 7 Utica/Watertown

FRNY-HMO-DSA1-001-S (2018)Standard Silver AI/NA Variation Individual Standard Silver 7 Utica/Watertown

FRNY-HMO-DS1-001-S-73 (2018) Standard Silver CSR AV73 Individual Standard Silver 7 Utica/Watertown



FRNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 7 Utica/Watertown

FRNY-HMO-DSA1-002-S (2018)Standard Silver 2 AI/NA Variation Individual Standard Silver 7 Utica/Watertown

FRNY-HMO-DS1-002-S-73 (2018) Standard Silver 2 CSR AV73 Individual Standard Silver 7 Utica/Watertown



FRNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 7 Utica/Watertown

FRNY-HMO-DGA1-001-S (2018) Standard Gold AI/NA Variation Individual Standard Gold 7 Utica/Watertown

FRNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 7 Utica/Watertown

FRNY-HMO-DGA1-002-S (2018)Standard Gold 2 AI/NA Variation Individual Standard Gold 7 Utica/Watertown

FRNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 7 Utica/Watertown

Exhibit C

2018

Child Only(1 Child)



$192.64 $385.28 $577.92

$192.64 $385.28 $577.92

$192.93 $385.86 $578.79

$192.93 $385.86 $578.79

$248.67 $497.34 $746.01

$248.67 $497.34 $746.01

$248.67 $497.34 $746.01

$248.67 $497.34 $746.01

$248.67 $497.34 $746.01

$254.32 $508.64 $762.96

$254.32 $508.64 $762.96

$254.32 $508.64 $762.96

$254.32 $508.64 $762.96

$254.32 $508.64 $762.96

$286.52 $573.04 $859.56

$286.52 $573.04 $859.56

$288.77 $577.54 $866.31

$288.77 $577.54 $866.31

$331.72 $663.44 $995.16

Page 84




FRNY-HMO-DPA1-001-S (2018)Standard Platinum AI/NA Variation Individual Standard Platinum 7 Utica/Watertown

FRNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 7 Utica/Watertown

FRNY-HMO-DBA1-001-N (2018)Non-Standard Bronze 1 AI/NA Variation Individual Non-Standard Bronze 7 Utica/Watertown

FRNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 7 Utica/Watertown

FRNY-HMO-DBA1-002-N (2018)Non-Standard Bronze 2 AI/NA Variation Individual Non-Standard Bronze 7 Utica/Watertown

FRNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 7 Utica/Watertown

FRNY-HMOH-DBA1-003-N (2018)Non-Standard Bronze 3 AI/NA Variation Individual Non-Standard Bronze 7 Utica/Watertown

FRNY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 7 Utica/Watertown

FRNY-HMO-DSA1-001-N (2018)Non-Standard Silver 1 AI/NA Variation Individual Non-Standard Silver 7 Utica/Watertown

FRNY-HMO-DS1-001-N-73 (2018)Non-Standard Silver 1 CSR AV73 Individual Non-Standard Silver 7 Utica/Watertown



FRNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 7 Utica/Watertown

FRNY-HMO-DSA1-002-N (2018)Non-Standard Silver 2 AI/NA Variation Individual Non-Standard Silver 7 Utica/Watertown




FRNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 7 Utica/Watertown

FRNY-HMOH-DSA1-003-N (2018)Non-Standard Silver 3 AI/NA Variation Individual Non-Standard Silver 7 Utica/Watertown

Exhibit C

2018

Child Only(1 Child)



$331.72 $663.44 $995.16

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

Page 85




FRNY-HMOH-DS1-003-N-73 (2018)Non-Standard Silver 3 CSR AV73 Individual Non-Standard Silver 7 Utica/Watertown



FRNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 7 Utica/Watertown

FRNY-HMO-DGA1-001-N (2018)Non-Standard Gold 1 AI/NA Variation Individual Non-Standard Gold 7 Utica/Watertown

FRNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 7 Utica/Watertown

FRNY-HMOH-DGA1-002-N (2018)Non-Standard Gold 2 AI/NA Variation Individual Non-Standard Gold 7 Utica/Watertown

FRNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 7 Utica/Watertown

FRNY-HMO-DPA1-001-N (2018)Non-Standard Platinum 1 AI/NA Variation Individual Non-Standard Platinum 7 Utica/Watertown

FRNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 7 Utica/Watertown

FRNY-HMO-DPA1-002-N (2018)Non-Standard Platinum 2 AI/NA Variation Individual Non-Standard Platinum 7 Utica/Watertown

FRNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 7 Utica/Watertown

FRNY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 7 Utica/Watertown

FRNY-HMOH-DGA1-001-NN (2018)Non-Standard Gold 1 National AI/NA Variation Individual Non-Standard Gold 7 Utica/Watertown

FRNY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 7 Utica/Watertown

FRNY-HMO-DPA1-001-NN (2018)Non-Standard Platinum 1 National AI/NA Variation Individual Non-Standard Platinum 7 Utica/Watertown


All Metal Levels excluding "Catastrophic" 1 Albany


All Metal Levels excluding "Catastrophic" 2 Buffalo

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

Page 86





All Metal Levels excluding "Catastrophic" 3 Mid-Hudson


All Metal Levels excluding "Catastrophic" 4 NYC


All Metal Levels excluding "Catastrophic" 5 Rochester


All Metal Levels excluding "Catastrophic" 6 Syracuse


All Metal Levels excluding "Catastrophic" 7 Utica/Watertown

NY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 1 AlbanyNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 1 AlbanyNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 1 AlbanyNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 1 AlbanyNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 1 AlbanyNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 1 AlbanyNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 1 AlbanyNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 1 AlbanyNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 1 AlbanyNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 1 AlbanyNY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 1 AlbanyNY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 1 Albany

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 1 Albany

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 1 AlbanyNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 1 AlbanyNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 1 AlbanyNY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 1 Albany

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 1 AlbanyNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 1 AlbanyNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 1 Albany

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/A

N/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/A

N/A N/A N/AN/A N/A N/AN/A N/A N/A

Page 87




NY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 1 AlbanyNY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 1 AlbanyNY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 1 AlbanyNY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 1 Albany

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 1 Albany

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 1 AlbanyNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 1 AlbanyNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 1 AlbanyNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 1 Albany

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 1 Albany

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 1 AlbanyNY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 1 AlbanyNY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 1 AlbanyNY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 1 AlbanyNY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 1 AlbanyNY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 1 AlbanyNY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 1 AlbanyNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 2 BuffaloNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 2 BuffaloNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 2 BuffaloNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 2 BuffaloNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 2 BuffaloNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 2 BuffaloNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 2 BuffaloNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 2 BuffaloNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 2 BuffaloNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 2 BuffaloNY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 2 BuffaloNY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 2 Buffalo

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 2 Buffalo

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 2 BuffaloNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 2 BuffaloNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 2 Buffalo

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/A

N/A N/A N/A


N/A N/A N/A$176.40 $352.80 $529.20$176.67 $353.34 $530.01$227.71 $455.42 $683.13$232.89 $465.78 $698.67$262.38 $524.76 $787.14$264.43 $528.86 $793.29$303.76 $607.52 $911.28

N/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/A


Page 88




NY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 2 Buffalo

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 2 BuffaloNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 2 BuffaloNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 2 BuffaloNY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 2 BuffaloNY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 2 BuffaloNY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 2 BuffaloNY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 2 Buffalo

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 2 Buffalo

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 2 BuffaloNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 2 BuffaloNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 2 BuffaloNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 2 Buffalo

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 2 Buffalo

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 2 BuffaloNY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 2 BuffaloNY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 2 BuffaloNY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 2 BuffaloNY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 2 BuffaloNY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 2 BuffaloNY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 2 BuffaloNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 3 Mid-HudsonNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 3 Mid-HudsonNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 3 Mid-HudsonNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 3 Mid-HudsonNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 3 Mid-HudsonNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 3 Mid-HudsonNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 3 Mid-HudsonNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 3 Mid-HudsonNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 3 Mid-HudsonNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 3 Mid-HudsonNY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 3 Mid-HudsonNY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 3 Mid-Hudson

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A

N/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/A

N/A N/A N/A


N/A N/A N/A$163.45 $326.90 $490.35$163.70 $327.40 $491.10$210.99 $421.98 $632.97$215.79 $431.58 $647.37$243.11 $486.22 $729.33$245.02 $490.04 $735.06$281.46 $562.92 $844.38


Page 89




NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 3 Mid-Hudson

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 3 Mid-HudsonNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 3 Mid-HudsonNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 3 Mid-HudsonNY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 3 Mid-Hudson

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 3 Mid-HudsonNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 3 Mid-HudsonNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 3 Mid-HudsonNY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 3 Mid-HudsonNY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 3 Mid-HudsonNY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 3 Mid-HudsonNY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 3 Mid-Hudson

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 3 Mid-Hudson

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 3 Mid-HudsonNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 3 Mid-HudsonNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 3 Mid-HudsonNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 3 Mid-Hudson

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 3 Mid-Hudson

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 3 Mid-HudsonNY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 3 Mid-HudsonNY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 3 Mid-HudsonNY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 3 Mid-HudsonNY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 3 Mid-HudsonNY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 3 Mid-HudsonNY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 3 Mid-HudsonNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 4 NYCNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 4 NYCNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 4 NYCNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 4 NYCNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 4 NYCNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 4 NYCNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 4 NYC

Exhibit C

2018

Child Only(1 Child)





N/A N/A N/A


N/A N/A N/A$226.75 $453.50 $680.25$227.10 $454.20 $681.30$292.70 $585.40 $878.10$299.36 $598.72 $898.08$337.26 $674.52 $1,011.78$339.91 $679.82 $1,019.73$390.46 $780.92 $1,171.38


Page 90




NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 4 NYCNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 4 NYCNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 4 NYCNY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 4 NYCNY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 4 NYC

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 4 NYC

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 4 NYCNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 4 NYCNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 4 NYCNY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 4 NYC

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 4 NYCNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 4 NYCNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 4 NYCNY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 4 NYCNY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 4 NYCNY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 4 NYCNY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 4 NYC

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 4 NYC

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 4 NYCNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 4 NYCNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 4 NYCNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 4 NYC

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 4 NYC

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 4 NYCNY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 4 NYCNY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 4 NYCNY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 4 NYCNY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 4 NYCNY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 4 NYCNY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 4 NYCNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 5 RochesterNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 5 Rochester

Exhibit C

2018

Child Only(1 Child)






N/A N/A N/A


N/A N/A N/A$211.61 $423.22 $634.83$211.93 $423.86 $635.79$273.16 $546.32 $819.48$279.37 $558.74 $838.11$314.74 $629.48 $944.22$317.21 $634.42 $951.63$364.39 $728.78 $1,093.17


Page 91




NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 5 RochesterNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 5 RochesterNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 5 RochesterNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 5 RochesterNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 5 RochesterNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 5 RochesterNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 5 RochesterNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 5 RochesterNY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 5 RochesterNY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 5 Rochester

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 5 Rochester

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 5 RochesterNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 5 RochesterNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 5 RochesterNY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 5 Rochester

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 5 RochesterNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 5 RochesterNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 5 RochesterNY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 5 RochesterNY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 5 RochesterNY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 5 RochesterNY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 5 Rochester

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 5 Rochester

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 5 RochesterNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 5 RochesterNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 5 RochesterNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 5 Rochester

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 5 Rochester

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 5 RochesterNY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 5 RochesterNY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 5 RochesterNY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 5 Rochester

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/AN/A N/A N/A



N/A N/A N/A


N/A N/A N/A$151.59 $303.18 $454.77$151.83 $303.66 $455.49$195.68 $391.36 $587.04$200.13 $400.26 $600.39

Page 92




NY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 5 RochesterNY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 5 RochesterNY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 5 RochesterNY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 6 SyracuseNY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 6 SyracuseNY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 6 SyracuseNY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 6 SyracuseNY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 6 SyracuseNY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 6 SyracuseNY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 6 SyracuseNY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 6 SyracuseNY-HMO-DB-002-N (2018) Non-Standard Bronze 2 Individual Non-Standard Bronze 6 SyracuseNY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 6 SyracuseNY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 6 SyracuseNY-HMO-DB-008-N (2018) Non-Standard Bronze 8 Individual Non-Standard Bronze 6 Syracuse

NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 6 Syracuse

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 6 SyracuseNY-HMO-DS-002-N (2018) Non-Standard Silver 2 Individual Non-Standard Silver 6 SyracuseNY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 6 SyracuseNY-HMO-DS-010-N (2018) Non-Standard Silver 10 Individual Non-Standard Silver 6 Syracuse

NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 6 SyracuseNY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 6 SyracuseNY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 6 SyracuseNY-HMO-DG-004-N (2018) Non-Standard Gold 4 Individual Non-Standard Gold 6 SyracuseNY-HMO-DG-005-N (2018) Non-Standard Gold 5 Individual Non-Standard Gold 6 SyracuseNY-HMO-DG-008-N (2018) Non-Standard Gold 8 Individual Non-Standard Gold 6 SyracuseNY-HMO-DG-009-N (2018) Non-Standard Gold 9 Individual Non-Standard Gold 6 Syracuse

NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 6 Syracuse

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 6 SyracuseNY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 6 SyracuseNY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 6 SyracuseNY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 6 Syracuse

Exhibit C

2018

Child Only(1 Child)



$225.48 $450.96 $676.44$227.24 $454.48 $681.72$261.04 $522.08 $783.12




N/A N/A N/A


Page 93




NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 6 Syracuse

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 6 SyracuseNY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 6 SyracuseNY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 6 SyracuseNY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 6 SyracuseNY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 6 SyracuseNY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 6 SyracuseNY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 6 Syracuse

NY-HMOH-DB-001-S (2018) Standard Bronze Individual Standard Bronze 7 Utica/Watertown

NY-HMO-DB-002-S (2018) Standard Bronze 2 Individual Standard Bronze 7 Utica/Watertown

NY-HMO-DS-001-S (2018) Standard Silver Individual Standard Silver 7 Utica/Watertown

NY-HMO-DS-002-S (2018) Standard Silver 2 Individual Standard Silver 7 Utica/Watertown

NY-HMO-DG-001-S (2018) Standard Gold Individual Standard Gold 7 Utica/Watertown

NY-HMO-DG-002-S (2018) Standard Gold 2 Individual Standard Gold 7 Utica/Watertown

NY-HMO-DP-001-S (2018) Standard Platinum Individual Standard Platinum 7 Utica/Watertown

NY-HMO-DB-001-N (2018) Non-Standard Bronze 1 Individual Non-Standard Bronze 7 Utica/Watertown


NY-HMOH-DB-003-N (2018) Non-Standard Bronze 3 Individual Non-Standard Bronze 7 Utica/Watertown

NY-HMOH-DB-006-N (2018) Non-Standard Bronze 6 Individual Non-Standard Bronze 7 Utica/Watertown


NY-HMOH-DB-001-NN (2018)Non-Standard Bronze 1 National Individual Non-Standard Bronze 7 Utica/Watertown

NY-HMO-DS-001-N (2018) Non-Standard Silver 1 Individual Non-Standard Silver 7 Utica/Watertown

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A$205.59 $411.18 $616.77$205.91 $411.82 $617.73$265.39 $530.78 $796.17$271.42 $542.84 $814.26$305.79 $611.58 $917.37$308.19 $616.38 $924.57$354.02 $708.04 $1,062.06

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

Page 94





NY-HMOH-DS-003-N (2018) Non-Standard Silver 3 Individual Non-Standard Silver 7 Utica/Watertown


NY-HMOH-DS-001-NN (2018) Non-Standard Silver 1 National Individual Non-Standard Silver 7 Utica/Watertown

NY-HMO-DG-001-N (2018) Non-Standard Gold 1 Individual Non-Standard Gold 7 Utica/Watertown

NY-HMOH-DG-002-N (2018) Non-Standard Gold 2 Individual Non-Standard Gold 7 Utica/Watertown





NY-HMOH-DG-001-NN (2018) Non-Standard Gold 1 National Individual Non-Standard Gold 7 Utica/Watertown

NY-POS-DP-001-S (2018) CompCare POS Replacement Individual Standard Platinum 7 Utica/Watertown

NY-HMO-DC-001-S (2018) Catastrophic Individual Standard Catastrophic 7 Utica/Watertown

NY-HMO-DP-001-N (2018) Non-Standard Platinum 1 Individual Non-Standard Platinum 7 Utica/Watertown

NY-HMO-DP-002-N (2018) Non-Standard Platinum 2 Individual Non-Standard Platinum 7 Utica/Watertown

NY-HMO-DP-001-NN (2018)Non-Standard Platinum 1 National Individual Non-Standard Platinum 7 Utica/Watertown

NY-HMOH-DB-001-S-CO (2018) Standard Bronze Individual Standard Bronze 7 Utica/Watertown

NY-HMO-DB-002-S-CO (2018) Standard Bronze 2 Individual Standard Bronze 7 Utica/Watertown

NY-HMO-DS-001-S-CO (2018) Standard Silver Individual Standard Silver 7 Utica/Watertown

Exhibit C

2018

Child Only(1 Child)



N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

$192.64 $385.28 $577.92

$192.93 $385.86 $578.79

$248.67 $497.34 $746.01

Page 95




NY-HMO-DS-002-S-CO (2018) Standard Silver 2 Individual Standard Silver 7 Utica/Watertown

NY-HMO-DG-001-S-CO (2018) Standard Gold Individual Standard Gold 7 Utica/Watertown

NY-HMO-DG-002-S-CO (2018) Standard Gold 2 Individual Standard Gold 7 Utica/Watertown

NY-HMO-DP-001-S-CO (2018) Standard Platinum Individual Standard Platinum 7 Utica/Watertown
























Exhibit C

2018

Child Only(1 Child)



$254.32 $508.64 $762.96

$286.52 $573.04 $859.56

$288.77 $577.54 $866.31

$331.72 $663.44 $995.16

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

3.00% 3.00% 3.00%

3.00% 3.00% 3.00%

3.00% 3.00% 3.00%

Page 96
















Exhibit C

2018

Child Only(1 Child)



3.00% 3.00% 3.00%

3.00% 3.00% 3.00%

3.00% 3.00% 3.00%

3.00% 3.00% 3.00%

Page 97

MVP Health Plan, Inc. Exhibit DPremiums by HIOS Plan IDEffective January 1, 2018Version 8/16/2017

HIOS Plan IDSmall vs Individual Rate Region

2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



56184NY0140010 Individual 1 Albany 1 $428.16 $856.32 $727.87 $1,220.26 N/A N/A N/A

56184NY0140010 Individual 2 Buffalo 1 $396.72 $793.44 $674.42 $1,130.65 N/A N/A N/A

56184NY0140010 Individual 3 Mid-Hudson 1 $550.36 $1,100.72 $935.61 $1,568.53 N/A N/A N/A

56184NY0140010 Individual 4 NYC 1 $513.61 $1,027.22 $873.14 $1,463.79 N/A N/A N/A

56184NY0140010 Individual 5 Rochester 1 $367.94 $735.88 $625.50 $1,048.63 N/A N/A N/A

56184NY0140010 Individual 6 Syracuse 1 $499.00 $998.00 $848.30 $1,422.15 N/A N/A N/A

56184NY0140010 Individual 7 Utica/Watertown 1 $467.57 $935.14 $794.87 $1,332.57 N/A N/A N/A






56184NY0140011 Individual 6 Syracuse 1 $503.99 $1,007.98 $856.78 $1,436.37 N/A N/A N/A


56184NY0140012 Individual 1 Albany 1 $552.69 $1,105.38 $939.57 $1,575.17 N/A N/A N/A

56184NY0140012 Individual 2 Buffalo 1 $512.11 $1,024.22 $870.59 $1,459.51 N/A N/A N/A

56184NY0140012 Individual 3 Mid-Hudson 1 $710.44 $1,420.88 $1,207.75 $2,024.75 N/A N/A N/A

56184NY0140012 Individual 4 NYC 1 $663.00 $1,326.00 $1,127.10 $1,889.55 N/A N/A N/A


56184NY0140012 Individual 6 Syracuse 1 $644.14 $1,288.28 $1,095.04 $1,835.80 N/A N/A N/A

56184NY0140012 Individual 7 Utica/Watertown 1 $603.56 $1,207.12 $1,026.05 $1,720.15 N/A N/A N/A








56184NY0140014 Individual 1 Albany 1 $636.84 $1,273.68 $1,082.63 $1,814.99 N/A N/A N/A

56184NY0140014 Individual 2 Buffalo 1 $590.08 $1,180.16 $1,003.14 $1,681.73 N/A N/A N/A



Page 98



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



56184NY0140014 Individual 5 Rochester 1 $547.27 $1,094.54 $930.36 $1,559.72 N/A N/A N/A














56184NY0140016 Individual 5 Rochester 1 $633.59 $1,267.18 $1,077.10 $1,805.73 N/A N/A N/A












56184NY0140018 Individual 3 Mid-Hudson 1 $1,098.49 $2,196.98 $1,867.43 $3,130.70 N/A N/A N/A

56184NY0140018 Individual 4 NYC 1 $1,025.14 $2,050.28 $1,742.74 $2,921.65 N/A N/A N/A





Page 99



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)







56184NY0140019 Individual 6 Syracuse 1 $1,005.94 $2,011.88 $1,710.10 $2,866.93 N/A N/A N/A




























Page 100



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 101



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)




















56184NY0140030 Individual 6 Syracuse 1 $499.77 $999.54 $849.61 $1,424.34 N/A N/A N/A















Page 102



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 103



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 104



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)
















56184NY0150009 Individual 7 Utica/Watertown 1 $576.48 $1,152.96 $980.01 $1,642.96 N/A N/A N/A



















Page 105



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 106



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 107



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 108



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 109



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 110



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 111



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 112



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 113



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)































Page 114



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)

























Page 115



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 116



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)

























56184NY0190005 Individual 1 Albany 1 $0.00 $0.00 $0.00 $0.00 $176.40 $352.80 $529.20

56184NY0190005 Individual 2 Buffalo 1 $0.00 $0.00 $0.00 $0.00 $163.45 $326.90 $490.35

56184NY0190005 Individual 3 Mid-Hudson 1 $0.00 $0.00 $0.00 $0.00 $226.75 $453.50 $680.25

56184NY0190005 Individual 4 NYC 1 $0.00 $0.00 $0.00 $0.00 $211.61 $423.22 $634.83

56184NY0190005 Individual 5 Rochester 1 $0.00 $0.00 $0.00 $0.00 $151.59 $303.18 $454.77

56184NY0190005 Individual 6 Syracuse 1 $0.00 $0.00 $0.00 $0.00 $205.59 $411.18 $616.77

56184NY0190005 Individual 7 Utica/Watertown 1 $0.00 $0.00 $0.00 $0.00 $192.64 $385.28 $577.92




Page 117



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)









56184NY0190007 Individual 3 Mid-Hudson 1 $0.00 $0.00 $0.00 $0.00 $337.26 $674.52 $1,011.78








56184NY0190008 Individual 4 NYC 1 $0.00 $0.00 $0.00 $0.00 $364.39 $728.78 $1,093.17


56184NY0190008 Individual 6 Syracuse 1 $0.00 $0.00 $0.00 $0.00 $354.02 $708.04 $1,062.06
















Page 118



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)













56184NY0190012 Individual 4 NYC 1 $0.00 $0.00 $0.00 $0.00 $375.32 $750.64 $1,125.96


56184NY0190012 Individual 6 Syracuse 1 $0.00 $0.00 $0.00 $0.00 $364.64 $729.28 $1,093.92

56184NY0190012 Individual 7 Utica/Watertown 1 $0.00 $0.00 $0.00 $0.00 $341.67 $683.34 $1,025.01













Page 119



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)


































Page 120



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 121



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 122



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



































Page 123



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)
































Page 124



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)



























Page 125



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)
























Page 126



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)
























Page 127



2018 Quarter Single

Single + Spouse

Single + Child(ren)


Child Only(1 Child)







56184NY0220002 Individual 1 Albany 1 $253.02 $506.04 $430.13 $721.11 N/A N/A N/A

56184NY0220002 Individual 2 Buffalo 1 $234.44 $468.88 $398.55 $668.15 N/A N/A N/A

56184NY0220002 Individual 3 Mid-Hudson 1 $325.23 $650.46 $552.89 $926.91 N/A N/A N/A

56184NY0220002 Individual 4 NYC 1 $303.51 $607.02 $515.97 $865.00 N/A N/A N/A

56184NY0220002 Individual 5 Rochester 1 $217.43 $434.86 $369.63 $619.68 N/A N/A N/A

56184NY0220002 Individual 6 Syracuse 1 $294.88 $589.76 $501.30 $840.41 N/A N/A N/A

56184NY0220002 Individual 7 Utica/Watertown 1 $276.30 $552.60 $469.71 $787.46 N/A N/A N/A

Page 128

MVP Health Plan, Inc. Exhibit EExample of Premium Calculation with RiderEffective January 1, 2018Version 8/16/2017

NYS Target Loss Ratio for Overall Book of Business 87.24%INDIVIDUAL ON

MVP Form ID FRNY-HMO-DP-001-S (2018) FRNY-HMO-DP-001-S (2018) FRNY-HMO-DP-001-S (2018) FRNY-HMO-DC-001-S (2018)Rate Region 1 Albany 1 Albany 1 Albany 1 AlbanyBenefit Description Standard Platinum Standard Platinum Standard Platinum CatastrophicSmall vs Individual Individual Individual Individual Single + Spouse + Child(ren)Metal Level Platinum Platinum Platinum CatastrophicContract Type Single + Spouse Single + Child(ren) Child Only Single + Child(ren)Family Planning Exclusion Rider? Not Available Not Available Not Available Not AvailableDomestic Partner Rider? In Base Benefit In Base Benefit Not Available In Base BenefitDependent Through Age 29 Rider? No Yes: FRNY-X-100 Not Available Not Available

A) 2018 Coplan Premium A $1,474.58 $1,253.39 $303.76 $430.13B) Family Planning Exclusion Rider BC) Domestic Partner Rider CD) Dependent Through Age 29 Rider D 1.00%Total Premium, after Rider(s)= [ A + B ] * [ 1 + C ] * [ 1 + D ] $1,474.58 $1,265.92 $303.76 $430.13

INDIVIDUAL OFF

MVP Form ID NY-HMO-DG-001-S (2018) NY-HMO-DG-001-S (2018) NY-HMO-DG-001-S (2018) NY-HMO-DG-001-S-CO (2018)Rate Region 1 Albany 1 Albany 1 Albany 1 AlbanyBenefit Description Standard Gold Standard Gold Standard Gold Standard GoldSmall vs Individual Individual Individual Individual IndividualMetal Level Gold Gold Gold GoldContract Type Single + Spouse Single + Child(ren) Single + Spouse + Child(ren) Child Only (1 Child)Family Planning Exclusion Rider? Not Available Not Available Not Available Not AvailableDomestic Partner Rider? In Base Benefit In Base Benefit In Base Benefit Not AvailableDependent Through Age 29 Rider? No Yes: NY-X-100 No Not AvailableUnlimited Skilled Nursing Facility Rider? No Yes: NY-X-USNF Yes: NY-X-USNF No

A) 2018 Coplan Premium A $1,273.68 $1,082.63 $1,814.99 $262.38B) Family Planning Exclusion Rider BC) Domestic Partner Rider CD) Dependent Through Age 29 Rider D 1.00%E) Unlimited Skilled Nursing Facility Rider E 3.00% 3.00%Total Premium, after Rider(s)= [ A + B ] * [ 1 + C ] * [ 1 + D ] * [ 1 + E ] $1,273.68 $1,126.26 $1,869.44 $262.38

Page 129

MVP Health Plan, Inc. Exhibit FAdjustment Factors For Major Variations From The Base PlanEffective January 1, 2018Version 8/16/2017

Base Plan Base Plan Variation AdjustmentCharacteristic Factor Characteristic Factor

Without Through Age 29 Coverage 1.000 With Through Age 29 Coverage 1.010With Family Planning Coverage 1.000 Without Family Planning Coverage N/A

With Domestic Partner Coverage 1.000 Without Domestic Partner Coverage N/AWithout Pediatric Dental Coverage 1.000 With Pediatric Dental Coverage N/A

The chart above is illustrative only. See Exhibit C for actual rates. The premium for some variation characteristics are filed as dollar amounts and not a percent/factor. Therefore, the factor will change depending on coplan chosen.

Page 130

MVP Health Plan, Inc. Exhibit GArea FactorEffective January 1, 2018Version 8/16/2017

County Rate Region by DFS

AR44 Licensed County

Factors for Individual

ALBANY 1 Albany Yes 0.967COLUMBIA 1 Albany Yes 0.967FULTON 1 Albany Yes 0.967GREENE 1 Albany Yes 0.967MONTGOMERY 1 Albany Yes 0.967RENSSELAER 1 Albany Yes 0.967SARATOGA 1 Albany Yes 0.967SCHENECTADY 1 Albany Yes 0.967SCHOHARIE 1 Albany Yes 0.967WARREN 1 Albany Yes 0.967WASHINGTON 1 Albany Yes 0.967ALLEGANY 2 Buffalo No 0.896CATTARAUGUS 2 Buffalo No 0.896CHAUTAUQUA 2 Buffalo No 0.896ERIE 2 Buffalo No 0.896GENESEE 2 Buffalo Yes 0.896NIAGARA 2 Buffalo No 0.896ORLEANS 2 Buffalo Yes 0.896WYOMING 2 Buffalo Yes 0.896DELAWARE 3 Mid-Hudson Yes 1.243DUTCHESS 3 Mid-Hudson Yes 1.243ORANGE 3 Mid-Hudson Yes 1.243PUTNAM 3 Mid-Hudson Yes 1.243SULLIVAN 3 Mid-Hudson Yes 1.243ULSTER 3 Mid-Hudson Yes 1.243BRONX 4 NYC No 1.160KINGS 4 NYC No 1.160NEW YORK 4 NYC No 1.160QUEENS 4 NYC No 1.160RICHMOND 4 NYC No 1.160ROCKLAND 4 NYC Yes 1.160WESTCHESTER 4 NYC Yes 1.160LIVINGSTON 5 Rochester Yes 0.831MONROE 5 Rochester Yes 0.831ONTARIO 5 Rochester Yes 0.831SENECA 5 Rochester Yes 0.831WAYNE 5 Rochester Yes 0.831YATES 5 Rochester Yes 0.831BROOME 6 Syracuse Yes 1.127CAYUGA 6 Syracuse Yes 1.127CHEMUNG 6 Syracuse No 1.127CORTLAND 6 Syracuse Yes 1.127ONONDAGA 6 Syracuse Yes 1.127SCHUYLER 6 Syracuse No 1.127STEUBEN 6 Syracuse Yes 1.127TIOGA 6 Syracuse Yes 1.127TOMPKINS 6 Syracuse Yes 1.127CHENANGO 7 Utica/Watertown Yes 1.056CLINTON 7 Utica/Watertown Yes 1.056ESSEX 7 Utica/Watertown Yes 1.056FRANKLIN 7 Utica/Watertown Yes 1.056HAMILTON 7 Utica/Watertown Yes 1.056HERKIMER 7 Utica/Watertown Yes 1.056JEFFERSON 7 Utica/Watertown Yes 1.056LEWIS 7 Utica/Watertown Yes 1.056MADISON 7 Utica/Watertown Yes 1.056

Page 131

MVP Health Plan, Inc. Exhibit GArea FactorEffective January 1, 2018Version 8/16/2017

County Rate Region by DFS

AR44 Licensed County

Factors for Individual

ONEIDA 7 Utica/Watertown Yes 1.056OSWEGO 7 Utica/Watertown Yes 1.056OTSEGO 7 Utica/Watertown Yes 1.056SAINT LAWRENCE 7 Utica/Watertown Yes 1.056NASSAU 8 Long Island No 1.413SUFFOLK 8 Long Island No 1.413

Page 132

MVP Health Plan, Inc. Exhibit HStandard Census Tiers and FactorsEffective January 1, 2018Version 8/16/2017

Contract Type FactorSingle 1.000Single + Spouse 2.000Single + Child(ren) 1.700Single + Spouse + Child(ren) 2.850Child Only 0.412

Page 133

New York State Individual Underwriting Guidelines

Eligibility for on-exchange products is determined by New York State of Health.

MVP does not sell every plan offered in each county within its service area. Please see the grid below for a summary of which plans are available for purchase in each county throughout MVP’s service area.

County Rate Region by DFS MVP Health Plan, Inc.

Licensed to Sell? ALBANY 1 Albany Yes

COLUMBIA 1 Albany Yes FULTON 1 Albany Yes GREENE 1 Albany Yes

MONTGOMERY 1 Albany Yes RENSSELAER 1 Albany Yes SARATOGA 1 Albany Yes

SCHENECTADY 1 Albany Yes SCHOHARIE 1 Albany Yes

WARREN 1 Albany Yes WASHINGTON 1 Albany Yes

ALLEGANY 2 Buffalo No CATTARAUGUS 2 Buffalo No CHAUTAUQUA 2 Buffalo No

ERIE 2 Buffalo No GENESEE 2 Buffalo Yes NIAGARA 2 Buffalo No ORLEANS 2 Buffalo Yes

WYOMING 2 Buffalo Yes DELAWARE 3 Mid-Hudson Yes DUTCHESS 3 Mid-Hudson Yes ORANGE 3 Mid-Hudson Yes PUTNAM 3 Mid-Hudson Yes SULLIVAN 3 Mid-Hudson Yes

ULSTER 3 Mid-Hudson Yes BRONX 4 NYC No KINGS 4 NYC No

NEW YORK 4 NYC No QUEENS 4 NYC No

RICHMOND 4 NYC No ROCKLAND 4 NYC Yes

WESTCHESTER 4 NYC Yes

Page 134 Exhibit I

County Rate Region by DFS MVP Health Plan, Inc.

Licensed to Sell?

LIVINGSTON 5 Rochester Yes

MONROE 5 Rochester Yes

ONTARIO 5 Rochester Yes

SENECA 5 Rochester Yes

WAYNE 5 Rochester Yes

YATES 5 Rochester Yes

BROOME 6 Syracuse Yes

CAYUGA 6 Syracuse Yes

CHEMUNG 6 Syracuse No

CORTLAND 6 Syracuse Yes

ONONDAGA 6 Syracuse Yes

SCHUYLER 6 Syracuse No

STEUBEN 6 Syracuse Yes

TIOGA 6 Syracuse Yes

TOMPKINS 6 Syracuse Yes

CHENANGO 7 Utica/Watertown Yes

CLINTON 7 Utica/Watertown Yes

ESSEX 7 Utica/Watertown Yes

FRANKLIN 7 Utica/Watertown Yes

HAMILTON 7 Utica/Watertown Yes

HERKIMER 7 Utica/Watertown Yes

JEFFERSON 7 Utica/Watertown Yes

LEWIS 7 Utica/Watertown Yes

MADISON 7 Utica/Watertown Yes

ONEIDA 7 Utica/Watertown Yes

OSWEGO 7 Utica/Watertown Yes

OTSEGO 7 Utica/Watertown Yes

SAINT LAWRENCE 7 Utica/Watertown Yes

NASSAU 8 Long Island No

SUFFOLK 8 Long Island No

Page 135 Exhibit I

MVP Broker Commission Program

NY State of Health™ Marketplace2017 Broker Commission Schedule—Effective January 1, 2017

NY State of Health Small Business (SHOP) 3.5 % of paid premium

NY State of Health Individual/Family Marketplace 2.5 % of paid premium

Brokers must be certified with an approved CE (continuing education) provider organization, and have an active Broker Agreement, New York license, and appointment with MVP Health Care, in order to receive commission on NY State of Health Exchange business.

General Provisions• General Provisions Brokers are paid commission based on the amount of monthly premium paid by each of the broker’s

NY State of Health SHOP and Individual Marketplace.

• Commissions are paid monthly.

• Commission statements are available each month and should be reviewed for potential discrepancies. Any discrepancy on commission payments should be reported to MVP immediately. MVP will consider retroactive adjustments to commission payments only for the six months prior to the current month’s statement.

• MVP reserves the right, in its sole discretion, to alter or void the compensation programs at any time in response to issues and conditions that affect the corporation, business, marketplace, or economy. Entitlement to commission and bonuses is subject to terms and conditions contained in the Broker Agreement. MVP reserves the right to make the final determination of eligibility for case (group/member) credit, premium credit, and commission/bonus payments. The forgoing commission rates may be changed at MVP’s option on 30 days notice to brokers. Any changes to the compensation program must be filed with and approved by the New York State Department of Financial Services.

MVPCOMM0055 (10/2016)

Page 136 Exhibit J

MVP Broker Commission Program

New York Off-Exchange2017 Broker Commission Schedule—Effective January 1, 2017

New York Individual/Family Off-Exchange 2.5 % of paid premium

New York Small Group Off-Exchange (1–100) 4.0 % of paid premium+ .25 % Administrative Retention Commission*Additional +.25 % Adminstrative Retention Commission for agencies with more than 2,000 small group members*1 % Administrative New Business Commission*

* The Administrative Commission amount is paid with monthly commission. Agencies must retain 90% of their small group membership from December 31, 2016 to January 1, 2017.

Individual/Small Group Dental Options

Delta Pediatric Dental Commission paid by Delta Dental

MVP Dental for Kids (Pediatrics) 10.0 % of paid premium

MVP Dental PPO (Family) 10.0 % of paid premium

MVP Adult Only Dental 10.0 % of paid premium

Large Group (101+)

EPO/PPO 4.0 % of paid premium for the first $1 million in premiums for all products†

2.5 % of paid premium thereafter†

HDHP 5.0 % of paid premium for the first $1 million in premiums for all products†

2.5 % of paid premium thereafter†

HMO/POS 4.0 % of paid premium for the first $1 million in premiums for all products

2.5 % of paid premium thereafter

MVP Dental (Fully Insured) 10.0 % of paid premium

† Unless otherwise negotiated at the time of the quote.

MVPCOMM0055 (09/2016)

Page 137 Exhibit J

MVP Broker Commission Program New York Off-Exchange

General Provisions• All groups must meet MVP’s eligibility and participation requirements.

• Large group commissions will be paid according to the Schedule unless otherwise negotiated.• Once the annual premiums accumulated for all large group medical products (EPO/PPO, HDHP, HMO/POS) combined

reach $1 million for the calendar year, the commissions will drop to the lower payout amount the first of the next month.• Brokers are paid commission based on the amount of monthly premium paid by each of the broker’s groups and

individual/family contracts.

• Commissions are paid monthly, with the exception of the Bonus Program.

• Commission statements are available each month and should be reviewed for potential discrepancies. Any discrepancy on commission payments should be reported to MVP immediately. MVP will only consider retroactive adjustments to commission payments for the six months prior to the current month’s statement.

• Negotiated commissions (EPO/PPO, HDHP products only) can range from 0–8 percent of paid premium. The in-force Broker of Record (BOR) sets the commission rate for the contract year for renewals. For new MVP business, the first broker to quote sets the commission rate for the initial contract year. Commission amounts are included in MVP’s monthly premium charged to the employer and transfer to the broker as part of their monthly commission. Commission amounts (including any other type of compensation paid to brokers) are included in MVP’s premiums for purposes of calculating the MLR as outlined in our rate manual.

• MVP reserves the right, in its sole discretion, to alter or void the compensation programs at any time in response to issues and conditions that affect the corporation, business, marketplace, or economy. Entitlement to commission and bonuses is subject to the terms and conditions contained in the MVP Broker Agreement. MVP reserves the right to make the final eligibility determinations for case (group/member) credit, premium credit, and commission/bonus payments. The forgoing commission rates may be changed at MVP’s discretion upon 30 days notice to brokers. Any changes to the compensation program must be filed with and approved by the New York State Department of Financial Services.

Page 138 Exhibit J

Group Medicare Advantage

Fully Insured (Three Contract Minimum)Gold HMO/GoldAnywhere PPO/USA Care PPO $12.50 per contract, per month

RXCare Stand-Alone PDP $3.50 per contract, per month

Experience Rated (500 Contract Minimum)Gold HMO/GoldAnywhere PPO/USA Care PPO $12.50 per contract, per month*

RXCare Stand-Alone PDP $3.50 per contract, per month*

* Per contract, per month commission for experience rated Group Medicare Advantage is applied directly to the groups’ per subscriber, per month rate. Commission may also be waived on experience rated Group Medicare Advantage program upon request via email or letter to MVP.

Group Medicare Advantage (Fully Insured and Experience Rated) contract must be in force for three months before payment is made, i.e. commission for contracts written in January will be paid in April. Pursuant to the CMS Medicare Guidelines, in the event that a Medicare enrollee disenrolls within less than 90 days after enrollment, any payment paid or accrued to broker will be returned to or withheld by MVP. Brokers must be MVP Medicare certified.

2017 Group Medicare Advantage BonusBonus is based on enrolled contracts for groups with January 1, 2017 effective date.

Number of Enrolled Contracts Bonus Payment

51–99 enrolled contracts $5,000 per group

100–500 enrolled contracts $10,000 per group

+ 501 enrolled contracts $25,000 per group

Bonus applies to new sales and total MVP takeover of group, which result in contract growth over 50 contracts.

MVP Broker Commission Program New York Off-Exchange

Page 139 Exhibit J

MVP Broker Bonus

New York State2017 Broker Bonus Schedule—Effective January 1, 2017

2017 Annual Large Group Retention BonusTo qualify for bonus, agency must have 200 large group HMO/EPO/PPO/HDHP/ASO contracts.

2016 Retention Rate by Membership Bonus Payment

90–94.99 % .3% for the inforce large group EPO/PPO/HDHP book’s annual collected premium up to $60,000 maximum

+ 95 % .6% for the inforce large group EPO/PPO/HDHP book’s annual collected premium up to $100,000 maximum

Retention percent will be based on a membership comparison of book of business on December 31, 2016 (Large Group HMO/EPO/PPO/ASO and compared to December 31, 2017 book of business (Large Group HMO/EPO/PPO/ASO).

2017 Large Group New Business BonusTo qualify for bonus, agency must maintain 85% retention on existing business* and meet the new business contracts and case counts below.

Number of New Contract(EPO/PPO/HDHP)

Number of Large New Cases(EPO/PPO/HDHP)

Bonus Payment

100–249 2 $15,000

250–499 2 $30,000

500–999 2 $60,000

1,000–1,499 2 $120,000

+ 1,500 3 $200,000

* Retention will be based on a membership comparison of book of business on December 31, 2016 (Large Group HMO/EPO/PPO/HDHP) and compared to December 31, 2017 book of business (Large Group HMO/EPO/PPO/HDHP).

2017 New January Sales BonusAgencies who sell a large Non-ASO/HMO total replacement group with 100+ enrolled subscribers will receive an additional $75 per contract payable May 2017.

MVPCOMM0055 (10/2016)

Page 140 Exhibit J

New York State2017 Broker Bonus Schedule—Effective January 1, 2017

General Provisions• Retention and New Business Bonus payout excludes membership counts from the following MVP products: Small Group,

HMO, Medicare Advantage, HNY Group, Chamber, Association, NY State of Health™ SHOP, and Individual Marketplace and MVP Individual Off-Exchange.

• The retention requirement for Agencies appointed with MVP January 1, 2017–December 31, 2017 will be based on a membership comparison of book of business as of date of appointment with MVP (large group HMO/EPO/PPO/ASO) compared to December 31, 2017 book of business percent calculation (large group HMO/EPO/PPO/ASO).

• ASO membership is used for the retention percentage determination only. There is no bonus payment for ASO membership retention.

• If a group changes broker of record (BOR) during the 2017 calendar year the group will be removed from the existing broker’s applicable base count on December 31, 2016 and the enrollment as of the current date will be added to the new broker’s applicable base count (December 31, 2016).

• Business transfer from non-applicable product lines (ASO, HMO, etc.) is excluded from bonus calculation.

• Bonus payment will be made by April 30, 2018.

• MVP reserves the right, in its sole discretion, to alter or void the compensation programs at any time in response to issues and conditions that affect the corporation, business, marketplace, or economy. Entitlement to commission and bonus is subject to terms and conditions contained in the Broker Agreement. MVP reserves the right to make the final determination of eligibility for case (group/member) credit, premium credit, and commission/bonus payments. The forgoing commission rates may be changed at MVP’s option on 30 days notice to brokers. Any changes to the compensation program must be filed with and approved by the New York State Department of Financial Services.

MVPCOMM0055 (10/2016)

MVP Broker Bonus New York Off-Exchange

Page 141 Exhibit J

table of contents for individual on and off exchange...mvp health plan, inc. effective january 1,...

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