mvp health services corp. - dfs portalhealt… · effective january 1, 2015 table of contents for...

MVP Health Services Corp.Effective January 1, 2015

Table of Contents

for

Small Group Off Exchange

Exhibit A Benefit Descriptions 1Exhibit A.1 Rider Descriptions 6Exhibit B Area Factor 7Exhibit C Premiums 9Exhibit D Example of Premium Calculation with Rider 29Exhibit E Commission Schedule 30Exhibit F Underwriting Guidelines 34

MVP Health Services Corp. Exhibit A

Benefit DescriptionsEffective January 1, 2015Version 9/25/14

MVP Form ID Form Description Plan Type

Small vs

Individual

Standard vs

Non-Standard Metal Level

Form Applies

to: On vs Off

Exchange

NY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off EPO Small Non-Standard Bronze Off

NY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off EPO Small Non-Standard Bronze Off

NY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 OffQHDHP EPO (Emb) Small Non-Standard Bronze Off



NY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off EPO Small Non-Standard Silver Off


NY-EPOH-SS-003-N (2015) Non-Standard Silver 3 OffQHDHP EPO (Agg) Small Non-Standard Silver Off


NY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off EPO Small Non-Standard Gold Off

NY-EPOH-SG-002-N (2015) Non-Standard Gold 2 OffQHDHP EPO (Agg) Small Non-Standard Gold Off

NY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off EPO Small Non-Standard Gold Off

NY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off EPO Small Non-Standard Platinum Off

NY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 OffQHDHP EPO (Emb) Small Non-Standard Bronze Off

NY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 OffQHDHP EPO (Agg) Small Non-Standard Silver Off

NY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off EPO Small Non-Standard Gold OffNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off EPO Small Non-Standard Platinum Off

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

Page 1

MVP Health Services Corp.


MVP Form ID

NY-EPO-SB-001-N (2015)

NY-EPO-SB-002-N (2015)

NY-EPOH-SB-003-N (2015)

NY-EPOH-SB-004-N (2015)

NY-EPOH-SB-005-N (2015)NY-EPO-SS-001-N (2015)

NY-EPO-SS-002-N (2015)

NY-EPOH-SS-003-N (2015)NY-EPO-SS-004-N (2015)

NY-EPO-SG-001-N (2015)

NY-EPOH-SG-002-N (2015)NY-EPO-SG-003-N (2015)

NY-EPO-SP-001-N (2015)

NY-HQNETHD-SB-001-N (2015)

NY-HQNETHD-SS-001-N (2015)NY-HQNET-SG-001-N (2015)NY-HQNET-SP-001-N (2015)


Exhibit A

Availble

to "Child

Only" Marketing Name

Single

Deductible

Medical

Family

Deductible

Medical

Single OOP

Maximum

Family OOP

Maximum

Emergency

Room

Inpatient

Stay/SNF

No MVP Liberty $3,500 $7,000 $6,350 $12,700 50% 50%

No MVP Liberty $4,000 $8,000 $6,350 $12,700 $350 no DD 30%

No MVP Liberty HDHP $4,000 $8,000 $6,350 $12,700 $300 30%

No MVP Liberty HDHP $5,000 $10,000 $6,350 $12,700 30% 30%

No MVP Liberty HDHP $3,000 $6,000 $6,350 $12,700 $100 50%No MVP Liberty $1,900 $3,800 $6,350 $12,700 $350 20%

No MVP Liberty $1,500 $3,000 $6,350 $12,700 $350 no DD 20%

No MVP Liberty HDHP $1,500 $3,000 $6,350 $12,700 $300 $500No MVP Liberty $2,500 $5,000 $6,350 $12,700 $300 $800

No MVP Liberty $850 $1,750 $6,350 $12,700 $300 no DD $500

No MVP Liberty HDHP $1,400 $2,800 $6,350 $12,700 $75 $200No MVP Liberty $600 $1,200 $4,000 $8,000 $250 $800

No MVP Liberty $0 $0 $3,000 $6,000 $100 $300

No MVP Liberty HDHP $5,500 $11,000 $6,350 $12,700 20% 20%

No MVP Liberty HDHP $2,000 $4,000 $6,350 $12,700 $150 $300No MVP Liberty $1,300 $2,600 $6,350 $12,700 $250 10%No MVP Liberty $0 $0 $2,300 $4,600 $70 $200

Page 2



MVP Form ID

NY-EPO-SB-001-N (2015)

NY-EPO-SB-002-N (2015)

NY-EPOH-SB-003-N (2015)

NY-EPOH-SB-004-N (2015)


NY-EPO-SS-002-N (2015)


NY-EPO-SG-001-N (2015)


NY-EPO-SP-001-N (2015)




Exhibit A

Outpatient

Facility

Physician

Surgery

Primary Care

Office

Specialist

Office

Mental

Heath Office

High Tech

Imaging

Diagnostic

Imaging PT/OT/ST

$300 $300 $35 $80 $80 $200 $100 $80

$300 $3003 visits at $0,

then $35 no DD $60 $60 $200 $100 $60

$100 $100 $30 $50 $50 $200 $100 $50

30% 30% $10 30% 30% 30% 30% 30%

50% 50% $5 50% 50% 50% 50% 50%$300 $200 $30 no DD $50 $50 $225 $125 $50

$200 $2003 visits at $0,

then $35 no DD $60 $60 $225 $125 $60

$200 $100 $25 $50 $50 $150 $50 $50$200 $100 $20 $50 $50 $180 $80 $50

$200 $100

3 visits at $0,then $15 no

DD $45 $45 $100 $60 $45

$100 $25 $5 $15 $15 $75 $15 $15$100 $50 $10 $40 $40 $150 $50 $40

$100 $1003 visits at $0,

then $5 $40 $40 $100 $40 $40

20% 20% $0 20% 20% 20% 20% 20%

$100 $0 $15 $30 $30 $100 $30 $3010% 10% $35 10% 10% 10% 10% 10%$100 $50 $10 $25 $25 $70 $25 $25

Page 3



MVP Form ID

NY-EPO-SB-001-N (2015)

NY-EPO-SB-002-N (2015)

NY-EPOH-SB-003-N (2015)

NY-EPOH-SB-004-N (2015)


NY-EPO-SS-002-N (2015)


NY-EPO-SG-001-N (2015)


NY-EPO-SP-001-N (2015)




Exhibit A

Out of Network

Lab

Dep Thru 29

Coverage

Pediatric Dental Available

Via

Tier 1

Prescriptio

n

Tier 2

Prescription

Tier 3

Prescription

$80 Optional Rider Stand Alone Dental Carrier $10 $40 50%

$60 Optional Rider Stand Alone Dental Carrier $8 $40 $60


30% Optional Rider Stand Alone Dental Carrier $5 $40 30%

50% Optional Rider Stand Alone Dental Carrier $5 $30 50%$50 Optional Rider Stand Alone Dental Carrier $8 $35 $70


$50 Optional Rider Stand Alone Dental Carrier $10 $40 $60$50 Optional Rider Stand Alone Dental Carrier $10 $35 50%


$15 Optional Rider Stand Alone Dental Carrier $5 $15 $25$40 Optional Rider Stand Alone Dental Carrier $10 $35 50%


20% Optional Rider Stand Alone Dental Carrier $5 $45 $90

$30 Optional Rider Stand Alone Dental Carrier $5 $25 $5010% Optional Rider Stand Alone Dental Carrier $5 $45 $90$25 Optional Rider Stand Alone Dental Carrier $5 $45 $90

Page 4



MVP Form ID

NY-EPO-SB-001-N (2015)

NY-EPO-SB-002-N (2015)

NY-EPOH-SB-003-N (2015)

NY-EPOH-SB-004-N (2015)


NY-EPO-SS-002-N (2015)


NY-EPO-SG-001-N (2015)


NY-EPO-SP-001-N (2015)




Exhibit A

Out of Network

Prescription

Deductible

IRS

Qualified

Plan

Single

Deductible

Family

Deductible Coinsurrance

Single Out of

Pocket Max

Family Out

of Pocket

Max

$200 No N/A N/A N/A N/A N/A

Integrated with Med No N/A N/A N/A N/A N/A

Integrated with Med Yes N/A N/A N/A N/A N/A


Integrated with Med Yes N/A N/A N/A N/A N/A$100 Brand Only No N/A N/A N/A N/A N/A

Integrated with Med No N/A N/A N/A N/A N/A

Integrated with Med Yes N/A N/A N/A N/A N/A$0 no N/A N/A N/A N/A N/A

$100 Brand Only No N/A N/A N/A N/A N/A

Integrated with Med Yes N/A N/A N/A N/A N/A$0 No N/A N/A N/A N/A N/A

$0 No N/A N/A N/A N/A N/A


Integrated with Med Yes N/A N/A N/A N/A N/A$0 No N/A N/A N/A N/A N/A$0 No N/A N/A N/A N/A N/A

Page 5

MVP Health Services Corp. Exhibit A.1

Rider DescriptionsEffective January 1, 2015Version 9/25/14

MVP Form ID

MVP Form for

Rate Distinction Benefit Description

Small vs

Individual

Standard vs Non-

Standard Metal Level

Available to

Child Only

Policies

Form Applies

to: On vs Off

Exchange

NY-E-399 NY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze No OffNY-E-399 NY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver No OffNY-E-399 NY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold No OffNY-E-399 NY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum No OffNY-E-100 NY-E-100 Dependent Through Age 29 Small Non-Standard All Metal Levels No OffNY-E-USNF NY-E-USNF Unlimited Skilled Nursing Facility Small Non-Standard All Metal Levels No Off

Page 6

MVP Health Services Corp. Exhibit B

Area FactorEffective January 1, 2015Version 9/25/14

Off Exchange: Small

County2014 Rate Region by DFS

Non-Standard (AR43)

Health Quest (HQ Net AR43)

2015 MVP Rate

Relativites -GROUP

ALBANY 1 Albany X No 0.9534COLUMBIA 1 Albany X No 0.9534FULTON 1 Albany X No 0.9534GREENE 1 Albany X No 0.9534MONTGOMERY 1 Albany X No 0.9534RENSSELAER 1 Albany X No 0.9534SARATOGA 1 Albany X No 0.9534SCHENECTADY 1 Albany X No 0.9534SCHOHARIE 1 Albany X No 0.9534WARREN 1 Albany X No 0.9534WASHINGTON 1 Albany X No 0.9534ALLEGANY 2 Buffalo No No 1.0566CATTARAUGUS 2 Buffalo No No 1.0566CHAUTAUQUA 2 Buffalo No No 1.0566ERIE 2 Buffalo X No 1.0566GENESEE 2 Buffalo X No 1.0566NIAGARA 2 Buffalo X No 1.0566ORLEANS 2 Buffalo X No 1.0566WYOMING 2 Buffalo X No 1.0566DELAWARE 3 Mid-Hudson X X 1.0725DUTCHESS 3 Mid-Hudson X X 1.0725ORANGE 3 Mid-Hudson X X 1.0725PUTNAM 3 Mid-Hudson X X 1.0725SULLIVAN 3 Mid-Hudson X X 1.0725ULSTER 3 Mid-Hudson X X 1.0725BRONX 4 NYC No No 1.2572KINGS 4 NYC No No 1.2572NEW YORK 4 NYC No No 1.2572QUEENS 4 NYC No No 1.2572RICHMOND 4 NYC No No 1.2572ROCKLAND 4 NYC X No 1.2572WESTCHESTER 4 NYC X No 1.2572LIVINGSTON 5 Rochester X No 0.7975MONROE 5 Rochester X No 0.7975ONTARIO 5 Rochester X No 0.7975SENECA 5 Rochester X No 0.7975WAYNE 5 Rochester X No 0.7975YATES 5 Rochester X No 0.7975BROOME 6 Syracuse X No 1.0358CAYUGA 6 Syracuse X No 1.0358CHEMUNG 6 Syracuse X No 1.0358CORTLAND 6 Syracuse X No 1.0358ONONDAGA 6 Syracuse X No 1.0358SCHUYLER 6 Syracuse X No 1.0358STEUBEN 6 Syracuse X No 1.0358TIOGA 6 Syracuse X No 1.0358TOMPKINS 6 Syracuse X No 1.0358CHENANGO 7 Utica/Watertown X No 0.9722CLINTON 7 Utica/Watertown X No 0.9722ESSEX 7 Utica/Watertown X No 0.9722FRANKLIN 7 Utica/Watertown X No 0.9722HAMILTON 7 Utica/Watertown X No 0.9722HERKIMER 7 Utica/Watertown X No 0.9722JEFFERSON 7 Utica/Watertown X No 0.9722LEWIS 7 Utica/Watertown X No 0.9722

Page 7

MVP Health Services Corp. Exhibit B

Area FactorEffective January 1, 2015Version 9/25/14

Off Exchange: Small

County2014 Rate Region by DFS

Non-Standard (AR43)

Health Quest (HQ Net AR43)

2015 MVP Rate

Relativites -GROUP

MADISON 7 Utica/Watertown X No 0.9722ONEIDA 7 Utica/Watertown X No 0.9722OSWEGO 7 Utica/Watertown X No 0.9722OTSEGO 7 Utica/Watertown X No 0.9722SAINT LAWRENCE 7 Utica/Watertown X No 0.9722NASSAU 8 Long Island Assoc No 1.2294SUFFOLK 8 Long Island Assoc No 1.2294

Page 8

MVP Health Services Corp. Exhibit C

PremiumsEffective January 1, 2015Version 9/25/14

First Quarter 2015 Second Quarter 2015

MVP Form ID Benefit Description

Small vs

Individual

Standard vs

Non-Standard Metal Level Rate Region Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +

Child(ren) Child Only

NY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 1 Albany $347.99 $695.98 $591.58 $991.77 N/ANY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 1 Albany $356.89 $713.78 $606.71 $1,017.14 N/ANY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 1 Albany $344.65 $689.30 $585.91 $982.25 N/ANY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 1 Albany $331.29 $662.58 $563.19 $944.18 N/ANY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 1 Albany $346.32 $692.64 $588.74 $987.01 N/ANY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 1 Albany $423.08 $846.16 $719.24 $1,205.78 N/ANY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 1 Albany $421.36 $842.72 $716.31 $1,200.88 N/ANY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 1 Albany $421.94 $843.88 $717.30 $1,202.53 N/ANY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 1 Albany $400.73 $801.46 $681.24 $1,142.08 N/ANY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 1 Albany $496.33 $992.66 $843.76 $1,414.54 N/ANY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 1 Albany $477.10 $954.20 $811.07 $1,359.74 N/ANY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 1 Albany $499.94 $999.88 $849.90 $1,424.83 N/ANY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 1 Albany $595.46 $1,190.92 $1,012.28 $1,697.06 N/ANY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 1 Albany N/A N/A N/A N/A N/ANY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 1 Albany N/A N/A N/A N/A N/ANY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 1 Albany N/A N/A N/A N/A N/ANY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 1 Albany N/A N/A N/A N/A N/ANY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 2 Buffalo $385.65 $771.30 $655.61 $1,099.10 N/ANY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 2 Buffalo $395.52 $791.04 $672.38 $1,127.23 N/ANY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 2 Buffalo $381.95 $763.90 $649.32 $1,088.56 N/ANY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 2 Buffalo $367.15 $734.30 $624.16 $1,046.38 N/ANY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 2 Buffalo $383.80 $767.60 $652.46 $1,093.83 N/ANY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 2 Buffalo $468.87 $937.74 $797.08 $1,336.28 N/ANY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 2 Buffalo $466.97 $933.94 $793.85 $1,330.86 N/ANY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 2 Buffalo $467.60 $935.20 $794.92 $1,332.66 N/ANY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 2 Buffalo $444.10 $888.20 $754.97 $1,265.69 N/ANY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 2 Buffalo $550.05 $1,100.10 $935.09 $1,567.64 N/ANY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 2 Buffalo $528.74 $1,057.48 $898.86 $1,506.91 N/ANY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 2 Buffalo $554.05 $1,108.10 $941.89 $1,579.04 N/ANY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 2 Buffalo $659.91 $1,319.82 $1,121.85 $1,880.74 N/ANY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 2 Buffalo N/A N/A N/A N/A N/ANY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 2 Buffalo N/A N/A N/A N/A N/ANY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 2 Buffalo N/A N/A N/A N/A N/ANY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 2 Buffalo N/A N/A N/A N/A N/ANY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 3 Mid-Hudson $391.46 $782.92 $665.48 $1,115.66 N/ANY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 3 Mid-Hudson $401.47 $802.94 $682.50 $1,144.19 N/ANY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 3 Mid-Hudson $387.70 $775.40 $659.09 $1,104.95 N/ANY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 3 Mid-Hudson $372.68 $745.36 $633.56 $1,062.14 N/ANY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 3 Mid-Hudson $389.58 $779.16 $662.29 $1,110.30 N/ANY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 3 Mid-Hudson $475.93 $951.86 $809.08 $1,356.40 N/ANY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 3 Mid-Hudson $474.00 $948.00 $805.80 $1,350.90 N/ANY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 3 Mid-Hudson $474.64 $949.28 $806.89 $1,352.72 N/ANY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 3 Mid-Hudson $450.79 $901.58 $766.34 $1,284.75 N/ANY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 3 Mid-Hudson $558.33 $1,116.66 $949.16 $1,591.24 N/ANY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 3 Mid-Hudson $536.70 $1,073.40 $912.39 $1,529.60 N/ANY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 3 Mid-Hudson $562.39 $1,124.78 $956.06 $1,602.81 N/A

Page 9





Small vs

Individual

Standard vs


Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


NY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 3 Mid-Hudson $669.85 $1,339.70 $1,138.75 $1,909.07 N/ANY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 3 Mid-Hudson $333.89 $667.78 $567.61 $951.59 N/ANY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 3 Mid-Hudson $423.63 $847.26 $720.17 $1,207.35 N/ANY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 3 Mid-Hudson $481.28 $962.56 $818.18 $1,371.65 N/ANY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 3 Mid-Hudson $613.73 $1,227.46 $1,043.34 $1,749.13 N/ANY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 4 NYC $458.87 $917.74 $780.08 $1,307.78 N/ANY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 4 NYC $470.61 $941.22 $800.04 $1,341.24 N/ANY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 4 NYC $454.47 $908.94 $772.60 $1,295.24 N/ANY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 4 NYC $436.86 $873.72 $742.66 $1,245.05 N/ANY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 4 NYC $456.67 $913.34 $776.34 $1,301.51 N/ANY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 4 NYC $557.90 $1,115.80 $948.43 $1,590.02 N/ANY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 4 NYC $555.63 $1,111.26 $944.57 $1,583.55 N/ANY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 4 NYC $556.39 $1,112.78 $945.86 $1,585.71 N/ANY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 4 NYC $528.42 $1,056.84 $898.31 $1,506.00 N/ANY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 4 NYC $654.49 $1,308.98 $1,112.63 $1,865.30 N/ANY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 4 NYC $629.13 $1,258.26 $1,069.52 $1,793.02 N/ANY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 4 NYC $659.24 $1,318.48 $1,120.71 $1,878.83 N/ANY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 4 NYC $785.21 $1,570.42 $1,334.86 $2,237.85 N/ANY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 4 NYC N/A N/A N/A N/A N/ANY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 4 NYC N/A N/A N/A N/A N/ANY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 4 NYC N/A N/A N/A N/A N/ANY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 4 NYC N/A N/A N/A N/A N/ANY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 5 Rochester $291.08 $582.16 $494.84 $829.58 N/ANY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 5 Rochester $298.53 $597.06 $507.50 $850.81 N/ANY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 5 Rochester $288.29 $576.58 $490.09 $821.63 N/ANY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 5 Rochester $277.12 $554.24 $471.10 $789.79 N/ANY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 5 Rochester $289.69 $579.38 $492.47 $825.62 N/ANY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 5 Rochester $353.90 $707.80 $601.63 $1,008.62 N/ANY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 5 Rochester $352.46 $704.92 $599.18 $1,004.51 N/ANY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 5 Rochester $352.94 $705.88 $600.00 $1,005.88 N/ANY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 5 Rochester $335.20 $670.40 $569.84 $955.32 N/ANY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 5 Rochester $415.17 $830.34 $705.79 $1,183.23 N/ANY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 5 Rochester $399.09 $798.18 $678.45 $1,137.41 N/ANY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 5 Rochester $418.19 $836.38 $710.92 $1,191.84 N/ANY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 5 Rochester $498.09 $996.18 $846.75 $1,419.56 N/ANY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 5 Rochester N/A N/A N/A N/A N/ANY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 5 Rochester N/A N/A N/A N/A N/ANY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 5 Rochester N/A N/A N/A N/A N/ANY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 5 Rochester N/A N/A N/A N/A N/ANY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 6 Syracuse $378.06 $756.12 $642.70 $1,077.47 N/ANY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 6 Syracuse $387.73 $775.46 $659.14 $1,105.03 N/ANY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 6 Syracuse $374.43 $748.86 $636.53 $1,067.13 N/ANY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 6 Syracuse $359.92 $719.84 $611.86 $1,025.77 N/ANY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 6 Syracuse $376.25 $752.50 $639.63 $1,072.31 N/ANY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 6 Syracuse $459.65 $919.30 $781.41 $1,310.00 N/ANY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 6 Syracuse $457.78 $915.56 $778.23 $1,304.67 N/A

Page 10





Small vs

Individual

Standard vs


Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


NY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 6 Syracuse $458.40 $916.80 $779.28 $1,306.44 N/ANY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 6 Syracuse $435.36 $870.72 $740.11 $1,240.78 N/ANY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 6 Syracuse $539.23 $1,078.46 $916.69 $1,536.81 N/ANY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 6 Syracuse $518.34 $1,036.68 $881.18 $1,477.27 N/ANY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 6 Syracuse $543.15 $1,086.30 $923.36 $1,547.98 N/ANY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 6 Syracuse $646.93 $1,293.86 $1,099.78 $1,843.75 N/ANY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 6 Syracuse N/A N/A N/A N/A N/ANY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 6 Syracuse N/A N/A N/A N/A N/ANY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 6 Syracuse N/A N/A N/A N/A N/ANY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 6 Syracuse N/A N/A N/A N/A N/A

NY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 7 Utica/ Watertown $354.85 $709.70 $603.25 $1,011.32 N/A

NY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 7 Utica/ Watertown $363.93 $727.86 $618.68 $1,037.20 N/A

NY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 7 Utica/ Watertown $351.44 $702.88 $597.45 $1,001.60 N/A

NY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 7 Utica/ Watertown $337.82 $675.64 $574.29 $962.79 N/A

NY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 7 Utica/ Watertown $353.14 $706.28 $600.34 $1,006.45 N/A

NY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 7 Utica/ Watertown $431.43 $862.86 $733.43 $1,229.58 N/A


NY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 7 Utica/ Watertown $430.26 $860.52 $731.44 $1,226.24 N/A


NY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 7 Utica/ Watertown $506.12 $1,012.24 $860.40 $1,442.44 N/A

NY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 7 Utica/ Watertown $486.51 $973.02 $827.07 $1,386.55 N/A

NY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 7 Utica/ Watertown $509.80 $1,019.60 $866.66 $1,452.93 N/A

NY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 7 Utica/ Watertown $607.20 $1,214.40 $1,032.24 $1,730.52 N/A

NY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 7 Utica/ Watertown N/A N/A N/A N/A N/A

NY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 7 Utica/ Watertown N/A N/A N/A N/A N/A

NY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 7 Utica/ Watertown N/A N/A N/A N/A N/A

NY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 7 Utica/ Watertown N/A N/A N/A N/A N/ANY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 8 Long Island $448.72 $897.44 $762.82 $1,278.85 N/ANY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 8 Long Island $460.20 $920.40 $782.34 $1,311.57 N/A

Page 11





Small vs

Individual

Standard vs


Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


NY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 8 Long Island $444.42 $888.84 $755.51 $1,266.60 N/ANY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 8 Long Island $427.20 $854.40 $726.24 $1,217.52 N/ANY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 8 Long Island $446.57 $893.14 $759.17 $1,272.72 N/ANY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 8 Long Island $545.56 $1,091.12 $927.45 $1,554.85 N/ANY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 8 Long Island $543.34 $1,086.68 $923.68 $1,548.52 N/ANY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 8 Long Island $544.08 $1,088.16 $924.94 $1,550.63 N/ANY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 8 Long Island $516.74 $1,033.48 $878.46 $1,472.71 N/ANY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 8 Long Island $640.02 $1,280.04 $1,088.03 $1,824.06 N/ANY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 8 Long Island $615.22 $1,230.44 $1,045.87 $1,753.38 N/ANY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 8 Long Island $644.66 $1,289.32 $1,095.92 $1,837.28 N/ANY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 8 Long Island $767.84 $1,535.68 $1,305.33 $2,188.34 N/ANY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 8 Long Island N/A N/A N/A N/A N/ANY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 8 Long Island N/A N/A N/A N/A N/ANY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 8 Long Island N/A N/A N/A N/A N/ANY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 8 Long Island N/A N/A N/A N/A N/A

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 1 Albany 0.49% 0.49% 0.49% 0.49% N/A

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 2 Buffalo 0.49% 0.49% 0.49% 0.49% N/A

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 3 Mid-Hudson 0.49% 0.49% 0.49% 0.49% N/A

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 4 NYC 0.49% 0.49% 0.49% 0.49% N/A

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 5 Rochester 0.49% 0.49% 0.49% 0.49% N/A

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 6 Syracuse 0.49% 0.49% 0.49% 0.49% N/A

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 7 Utica/ Watertown 0.49% 0.49% 0.49% 0.49% N/A

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 8 Long Island 0.49% 0.49% 0.49% 0.49% N/A

NY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 1 Albany -$1.79 -$3.58 -$3.04 -$5.10 N/ANY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 1 Albany -$2.09 -$4.18 -$3.55 -$5.96 N/ANY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 1 Albany -$2.39 -$4.78 -$4.06 -$6.81 N/ANY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 1 Albany -$2.69 -$5.38 -$4.57 -$7.67 N/ANY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 2 Buffalo -$1.99 -$3.98 -$3.38 -$5.67 N/ANY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 2 Buffalo -$2.32 -$4.64 -$3.94 -$6.61 N/A

Page 12





Small vs

Individual

Standard vs


Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


NY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 2 Buffalo -$2.65 -$5.30 -$4.51 -$7.55 N/ANY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 2 Buffalo -$2.98 -$5.96 -$5.07 -$8.49 N/ANY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 3 Mid-Hudson -$2.02 -$4.04 -$3.43 -$5.76 N/ANY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 3 Mid-Hudson -$2.35 -$4.70 -$4.00 -$6.70 N/ANY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 3 Mid-Hudson -$2.69 -$5.38 -$4.57 -$7.67 N/ANY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 3 Mid-Hudson -$3.03 -$6.06 -$5.15 -$8.64 N/ANY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 4 NYC -$2.37 -$4.74 -$4.03 -$6.75 N/ANY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 4 NYC -$2.76 -$5.52 -$4.69 -$7.87 N/ANY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 4 NYC -$3.15 -$6.30 -$5.36 -$8.98 N/ANY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 4 NYC -$3.55 -$7.10 -$6.04 -$10.12 N/ANY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 5 Rochester -$1.50 -$3.00 -$2.55 -$4.28 N/ANY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 5 Rochester -$1.75 -$3.50 -$2.98 -$4.99 N/ANY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 5 Rochester -$2.00 -$4.00 -$3.40 -$5.70 N/ANY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 5 Rochester -$2.25 -$4.50 -$3.83 -$6.41 N/ANY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 6 Syracuse -$1.95 -$3.90 -$3.32 -$5.56 N/ANY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 6 Syracuse -$2.27 -$4.54 -$3.86 -$6.47 N/ANY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 6 Syracuse -$2.60 -$5.20 -$4.42 -$7.41 N/ANY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 6 Syracuse -$2.92 -$5.84 -$4.96 -$8.32 N/A

NY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 7 Utica/ Watertown -$1.83 -$3.66 -$3.11 -$5.22 N/A

NY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 7 Utica/ Watertown -$2.13 -$4.26 -$3.62 -$6.07 N/A

NY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 7 Utica/ Watertown -$2.44 -$4.88 -$4.15 -$6.95 N/A

NY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 7 Utica/ Watertown -$2.74 -$5.48 -$4.66 -$7.81 N/ANY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 8 Long Island -$2.31 -$4.62 -$3.93 -$6.58 N/ANY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 8 Long Island -$2.70 -$5.40 -$4.59 -$7.70 N/ANY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 8 Long Island -$3.09 -$6.18 -$5.25 -$8.81 N/ANY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 8 Long Island -$3.47 -$6.94 -$5.90 -$9.89 N/A

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 1 Albany 3.00% 3.00% 3.00% 3.00% N/A

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 2 Buffalo 3.00% 3.00% 3.00% 3.00% N/A

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 3 Mid-Hudson 3.00% 3.00% 3.00% 3.00% N/A

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 4 NYC 3.00% 3.00% 3.00% 3.00% N/A

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 5 Rochester 3.00% 3.00% 3.00% 3.00% N/A

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 6 Syracuse 3.00% 3.00% 3.00% 3.00% N/A

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 7 Utica/ Watertown 3.00% 3.00% 3.00% 3.00% N/A

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 8 Long Island 3.00% 3.00% 3.00% 3.00% N/A

Page 13



First Quarter 2015


Small vs

Individual

Standard vs

Non-Standard Metal Level Rate Region

NY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 1 AlbanyNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 1 AlbanyNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 1 AlbanyNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 1 AlbanyNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 1 AlbanyNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 1 AlbanyNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 1 AlbanyNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 1 AlbanyNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 1 AlbanyNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 1 AlbanyNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 1 AlbanyNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 2 BuffaloNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 2 BuffaloNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 2 BuffaloNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 2 BuffaloNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 2 BuffaloNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 2 BuffaloNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 2 BuffaloNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 2 BuffaloNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 2 BuffaloNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 2 BuffaloNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 2 BuffaloNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 2 BuffaloNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 2 BuffaloNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 2 BuffaloNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 3 Mid-HudsonNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 3 Mid-HudsonNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 3 Mid-HudsonNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 3 Mid-HudsonNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 3 Mid-HudsonNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 3 Mid-HudsonNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 3 Mid-Hudson

Exhibit C

Second Quarter 2015 Third Quarter 2015

Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


$353.56 $707.12 $601.05 $1,007.65 N/A$362.60 $725.20 $616.42 $1,033.41 N/A$350.16 $700.32 $595.27 $997.96 N/A$336.59 $673.18 $572.20 $959.28 N/A$351.86 $703.72 $598.16 $1,002.80 N/A$429.85 $859.70 $730.75 $1,225.07 N/A$428.10 $856.20 $727.77 $1,220.09 N/A$428.69 $857.38 $728.77 $1,221.77 N/A$407.14 $814.28 $692.14 $1,160.35 N/A$504.27 $1,008.54 $857.26 $1,437.17 N/A$484.73 $969.46 $824.04 $1,381.48 N/A$507.94 $1,015.88 $863.50 $1,447.63 N/A$604.99 $1,209.98 $1,028.48 $1,724.22 N/A

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/A

$391.82 $783.64 $666.09 $1,116.69 N/A$401.85 $803.70 $683.15 $1,145.27 N/A$388.06 $776.12 $659.70 $1,105.97 N/A$373.02 $746.04 $634.13 $1,063.11 N/A$389.94 $779.88 $662.90 $1,111.33 N/A$476.37 $952.74 $809.83 $1,357.65 N/A$474.44 $948.88 $806.55 $1,352.15 N/A$475.08 $950.16 $807.64 $1,353.98 N/A$451.21 $902.42 $767.06 $1,285.95 N/A$558.85 $1,117.70 $950.05 $1,592.72 N/A$537.20 $1,074.40 $913.24 $1,531.02 N/A$562.91 $1,125.82 $956.95 $1,604.29 N/A$670.47 $1,340.94 $1,139.80 $1,910.84 N/A


$397.72 $795.44 $676.12 $1,133.50 N/A$407.89 $815.78 $693.41 $1,162.49 N/A$393.90 $787.80 $669.63 $1,122.62 N/A$378.64 $757.28 $643.69 $1,079.12 N/A$395.81 $791.62 $672.88 $1,128.06 N/A$483.54 $967.08 $822.02 $1,378.09 N/A$481.58 $963.16 $818.69 $1,372.50 N/A$482.23 $964.46 $819.79 $1,374.36 N/A$458.00 $916.00 $778.60 $1,305.30 N/A$567.26 $1,134.52 $964.34 $1,616.69 N/A$545.29 $1,090.58 $926.99 $1,554.08 N/A$571.39 $1,142.78 $971.36 $1,628.46 N/A

Page 14



First Quarter 2015


Small vs

Individual

Standard vs


NY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 3 Mid-HudsonNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 3 Mid-HudsonNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 3 Mid-HudsonNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 3 Mid-HudsonNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 3 Mid-HudsonNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 4 NYCNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 4 NYCNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 4 NYCNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 4 NYCNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 4 NYCNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 4 NYCNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 4 NYCNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 4 NYCNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 4 NYCNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 4 NYCNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 4 NYCNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 4 NYCNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 4 NYCNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 4 NYCNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 4 NYCNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 4 NYCNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 4 NYCNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 5 RochesterNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 5 RochesterNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 5 RochesterNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 5 RochesterNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 5 RochesterNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 5 RochesterNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 5 RochesterNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 5 RochesterNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 5 RochesterNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 5 RochesterNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 5 RochesterNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 5 RochesterNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 5 RochesterNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 5 RochesterNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 5 RochesterNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 5 RochesterNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 5 RochesterNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 6 SyracuseNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 6 SyracuseNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 6 SyracuseNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 6 SyracuseNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 6 SyracuseNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 6 SyracuseNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 6 Syracuse

Exhibit C


Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


$680.57 $1,361.14 $1,156.97 $1,939.62 N/A$339.23 $678.46 $576.69 $966.81 N/A$430.41 $860.82 $731.70 $1,226.67 N/A$488.98 $977.96 $831.27 $1,393.59 N/A$623.55 $1,247.10 $1,060.04 $1,777.12 N/A$466.21 $932.42 $792.56 $1,328.70 N/A$478.14 $956.28 $812.84 $1,362.70 N/A$461.74 $923.48 $784.96 $1,315.96 N/A$443.85 $887.70 $754.55 $1,264.97 N/A$463.98 $927.96 $788.77 $1,322.34 N/A$566.83 $1,133.66 $963.61 $1,615.47 N/A$564.52 $1,129.04 $959.68 $1,608.88 N/A$565.29 $1,130.58 $960.99 $1,611.08 N/A$536.87 $1,073.74 $912.68 $1,530.08 N/A$664.96 $1,329.92 $1,130.43 $1,895.14 N/A$639.20 $1,278.40 $1,086.64 $1,821.72 N/A$669.79 $1,339.58 $1,138.64 $1,908.90 N/A$797.77 $1,595.54 $1,356.21 $2,273.64 N/A


$295.74 $591.48 $502.76 $842.86 N/A$303.31 $606.62 $515.63 $864.43 N/A$292.90 $585.80 $497.93 $834.77 N/A$281.55 $563.10 $478.64 $802.42 N/A$294.33 $588.66 $500.36 $838.84 N/A$359.56 $719.12 $611.25 $1,024.75 N/A$358.10 $716.20 $608.77 $1,020.59 N/A$358.59 $717.18 $609.60 $1,021.98 N/A$340.56 $681.12 $578.95 $970.60 N/A$421.81 $843.62 $717.08 $1,202.16 N/A$405.48 $810.96 $689.32 $1,155.62 N/A$424.88 $849.76 $722.30 $1,210.91 N/A$506.06 $1,012.12 $860.30 $1,442.27 N/A


$384.11 $768.22 $652.99 $1,094.71 N/A$393.93 $787.86 $669.68 $1,122.70 N/A$380.42 $760.84 $646.71 $1,084.20 N/A$365.68 $731.36 $621.66 $1,042.19 N/A$382.27 $764.54 $649.86 $1,089.47 N/A$467.00 $934.00 $793.90 $1,330.95 N/A$465.10 $930.20 $790.67 $1,325.54 N/A

Page 15



First Quarter 2015


Small vs

Individual

Standard vs


NY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 6 SyracuseNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 6 SyracuseNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 6 SyracuseNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 6 SyracuseNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 6 SyracuseNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 6 SyracuseNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 6 SyracuseNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 6 SyracuseNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 6 SyracuseNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 6 Syracuse

NY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 7 Utica/ Watertown


NY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 7 Utica/ Watertown



NY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 7 Utica/ Watertown


NY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 7 Utica/ Watertown


NY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 7 Utica/ Watertown

NY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 7 Utica/ Watertown


NY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 7 Utica/ Watertown

NY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 7 Utica/ Watertown

NY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 7 Utica/ Watertown

NY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 7 Utica/ Watertown

NY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 7 Utica/ WatertownNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 8 Long IslandNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 8 Long Island

Exhibit C


Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


$465.73 $931.46 $791.74 $1,327.33 N/A$442.33 $884.66 $751.96 $1,260.64 N/A$547.86 $1,095.72 $931.36 $1,561.40 N/A$526.63 $1,053.26 $895.27 $1,500.90 N/A$551.84 $1,103.68 $938.13 $1,572.74 N/A$657.28 $1,314.56 $1,117.38 $1,873.25 N/A


$360.53 $721.06 $612.90 $1,027.51 N/A

$369.75 $739.50 $628.58 $1,053.79 N/A

$357.06 $714.12 $607.00 $1,017.62 N/A

$343.23 $686.46 $583.49 $978.21 N/A

$358.79 $717.58 $609.94 $1,022.55 N/A

$438.33 $876.66 $745.16 $1,249.24 N/A

$436.54 $873.08 $742.12 $1,244.14 N/A

$437.14 $874.28 $743.14 $1,245.85 N/A

$415.17 $830.34 $705.79 $1,183.23 N/A

$514.22 $1,028.44 $874.17 $1,465.53 N/A

$494.29 $988.58 $840.29 $1,408.73 N/A

$517.96 $1,035.92 $880.53 $1,476.19 N/A

$616.92 $1,233.84 $1,048.76 $1,758.22 N/A

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

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

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

N/A N/A N/A N/A N/A$455.90 $911.80 $775.03 $1,299.32 N/A$467.56 $935.12 $794.85 $1,332.55 N/A

Page 16



First Quarter 2015


Small vs

Individual

Standard vs


NY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 8 Long IslandNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 8 Long IslandNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 8 Long IslandNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 8 Long IslandNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 8 Long IslandNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 8 Long IslandNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 8 Long IslandNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 8 Long IslandNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 8 Long IslandNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 8 Long IslandNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 8 Long IslandNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 8 Long IslandNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 8 Long IslandNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 8 Long IslandNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 8 Long Island

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 1 Albany

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 2 Buffalo

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 3 Mid-Hudson

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 4 NYC

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 5 Rochester

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 6 Syracuse

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 7 Utica/ Watertown

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 8 Long Island

NY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 1 AlbanyNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 1 AlbanyNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 1 AlbanyNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 1 AlbanyNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 2 BuffaloNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 2 Buffalo

Exhibit C


Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


$451.53 $903.06 $767.60 $1,286.86 N/A$434.04 $868.08 $737.87 $1,237.01 N/A$453.72 $907.44 $771.32 $1,293.10 N/A$554.29 $1,108.58 $942.29 $1,579.73 N/A$552.03 $1,104.06 $938.45 $1,573.29 N/A$552.79 $1,105.58 $939.74 $1,575.45 N/A$525.01 $1,050.02 $892.52 $1,496.28 N/A$650.26 $1,300.52 $1,105.44 $1,853.24 N/A$625.06 $1,250.12 $1,062.60 $1,781.42 N/A$654.97 $1,309.94 $1,113.45 $1,866.66 N/A$780.13 $1,560.26 $1,326.22 $2,223.37 N/A


0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A-$1.82 -$3.64 -$3.09 -$5.19 N/A-$2.12 -$4.24 -$3.60 -$6.04 N/A-$2.43 -$4.86 -$4.13 -$6.93 N/A-$2.73 -$5.46 -$4.64 -$7.78 N/A-$2.02 -$4.04 -$3.43 -$5.76 N/A-$2.36 -$4.72 -$4.01 -$6.73 N/A

Page 17



First Quarter 2015


Small vs

Individual

Standard vs


NY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 2 BuffaloNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 2 BuffaloNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 3 Mid-HudsonNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 3 Mid-HudsonNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 3 Mid-HudsonNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 3 Mid-HudsonNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 4 NYCNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 4 NYCNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 4 NYCNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 4 NYCNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 5 RochesterNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 5 RochesterNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 5 RochesterNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 5 RochesterNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 6 SyracuseNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 6 SyracuseNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 6 SyracuseNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 6 Syracuse

NY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 7 Utica/ Watertown

NY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 7 Utica/ Watertown

NY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 7 Utica/ Watertown

NY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 7 Utica/ WatertownNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 8 Long IslandNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 8 Long IslandNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 8 Long IslandNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 8 Long Island

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 1 Albany

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 2 Buffalo

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 3 Mid-Hudson

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 4 NYC

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 5 Rochester

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 6 Syracuse

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 7 Utica/ Watertown

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 8 Long Island

Exhibit C


Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


-$2.69 -$5.38 -$4.57 -$7.67 N/A-$3.03 -$6.06 -$5.15 -$8.64 N/A-$2.05 -$4.10 -$3.49 -$5.84 N/A-$2.39 -$4.78 -$4.06 -$6.81 N/A-$2.73 -$5.46 -$4.64 -$7.78 N/A-$3.08 -$6.16 -$5.24 -$8.78 N/A-$2.41 -$4.82 -$4.10 -$6.87 N/A-$2.80 -$5.60 -$4.76 -$7.98 N/A-$3.20 -$6.40 -$5.44 -$9.12 N/A-$3.61 -$7.22 -$6.14 -$10.29 N/A-$1.52 -$3.04 -$2.58 -$4.33 N/A-$1.78 -$3.56 -$3.03 -$5.07 N/A-$2.03 -$4.06 -$3.45 -$5.79 N/A-$2.29 -$4.58 -$3.89 -$6.53 N/A-$1.98 -$3.96 -$3.37 -$5.64 N/A-$2.31 -$4.62 -$3.93 -$6.58 N/A-$2.64 -$5.28 -$4.49 -$7.52 N/A-$2.97 -$5.94 -$5.05 -$8.46 N/A

-$1.86 -$3.72 -$3.16 -$5.30 N/A

-$2.16 -$4.32 -$3.67 -$6.16 N/A

-$2.48 -$4.96 -$4.22 -$7.07 N/A

-$2.78 -$5.56 -$4.73 -$7.92 N/A-$2.35 -$4.70 -$4.00 -$6.70 N/A-$2.74 -$5.48 -$4.66 -$7.81 N/A-$3.14 -$6.28 -$5.34 -$8.95 N/A-$3.53 -$7.06 -$6.00 -$10.06 N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

Page 18



First Quarter 2015


Small vs

Individual

Standard vs


NY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 1 AlbanyNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 1 AlbanyNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 1 AlbanyNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 1 AlbanyNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 1 AlbanyNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 1 AlbanyNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 1 AlbanyNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 1 AlbanyNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 1 AlbanyNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 1 AlbanyNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 1 AlbanyNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 2 BuffaloNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 2 BuffaloNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 2 BuffaloNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 2 BuffaloNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 2 BuffaloNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 2 BuffaloNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 2 BuffaloNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 2 BuffaloNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 2 BuffaloNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 2 BuffaloNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 2 BuffaloNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 2 BuffaloNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 2 BuffaloNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 2 BuffaloNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 3 Mid-HudsonNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 3 Mid-HudsonNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 3 Mid-HudsonNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 3 Mid-HudsonNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 3 Mid-HudsonNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 3 Mid-HudsonNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 3 Mid-HudsonNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 3 Mid-Hudson

Exhibit C

Third Quarter 2015 Fourth Quarter 2015

Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


$359.22 $718.44 $610.67 $1,023.78 N/A$368.40 $736.80 $626.28 $1,049.94 N/A$355.76 $711.52 $604.79 $1,013.92 N/A$341.98 $683.96 $581.37 $974.64 N/A$357.49 $714.98 $607.73 $1,018.85 N/A$436.73 $873.46 $742.44 $1,244.68 N/A$434.95 $869.90 $739.42 $1,239.61 N/A$435.55 $871.10 $740.44 $1,241.32 N/A$413.65 $827.30 $703.21 $1,178.90 N/A$512.34 $1,024.68 $870.98 $1,460.17 N/A$492.49 $984.98 $837.23 $1,403.60 N/A$516.07 $1,032.14 $877.32 $1,470.80 N/A$614.67 $1,229.34 $1,044.94 $1,751.81 N/A


$398.09 $796.18 $676.75 $1,134.56 N/A$408.28 $816.56 $694.08 $1,163.60 N/A$394.27 $788.54 $670.26 $1,123.67 N/A$378.99 $757.98 $644.28 $1,080.12 N/A$396.18 $792.36 $673.51 $1,129.11 N/A$483.99 $967.98 $822.78 $1,379.37 N/A$482.03 $964.06 $819.45 $1,373.79 N/A$482.68 $965.36 $820.56 $1,375.64 N/A$458.43 $916.86 $779.33 $1,306.53 N/A$567.79 $1,135.58 $965.24 $1,618.20 N/A$545.80 $1,091.60 $927.86 $1,555.53 N/A$571.92 $1,143.84 $972.26 $1,629.97 N/A$681.20 $1,362.40 $1,158.04 $1,941.42 N/A


$404.08 $808.16 $686.94 $1,151.63 N/A$414.42 $828.84 $704.51 $1,181.10 N/A$400.20 $800.40 $680.34 $1,140.57 N/A$384.70 $769.40 $653.99 $1,096.40 N/A$402.14 $804.28 $683.64 $1,146.10 N/A$491.28 $982.56 $835.18 $1,400.15 N/A$489.29 $978.58 $831.79 $1,394.48 N/A$489.95 $979.90 $832.92 $1,396.36 N/A$465.33 $930.66 $791.06 $1,326.19 N/A$576.34 $1,152.68 $979.78 $1,642.57 N/A$554.01 $1,108.02 $941.82 $1,578.93 N/A$580.53 $1,161.06 $986.90 $1,654.51 N/A

Page 19



First Quarter 2015


Small vs

Individual

Standard vs


NY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 3 Mid-HudsonNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 3 Mid-HudsonNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 3 Mid-HudsonNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 3 Mid-HudsonNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 3 Mid-HudsonNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 4 NYCNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 4 NYCNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 4 NYCNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 4 NYCNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 4 NYCNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 4 NYCNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 4 NYCNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 4 NYCNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 4 NYCNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 4 NYCNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 4 NYCNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 4 NYCNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 4 NYCNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 4 NYCNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 4 NYCNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 4 NYCNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 4 NYCNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 5 RochesterNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 5 RochesterNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 5 RochesterNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 5 RochesterNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 5 RochesterNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 5 RochesterNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 5 RochesterNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 5 RochesterNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 5 RochesterNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 5 RochesterNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 5 RochesterNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 5 RochesterNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 5 RochesterNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 5 RochesterNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 5 RochesterNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 5 RochesterNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 5 RochesterNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 6 SyracuseNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 6 SyracuseNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 6 SyracuseNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 6 SyracuseNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 6 SyracuseNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 6 SyracuseNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 6 Syracuse

Exhibit C


Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


$691.46 $1,382.92 $1,175.48 $1,970.66 N/A$344.66 $689.32 $585.92 $982.28 N/A$437.30 $874.60 $743.41 $1,246.31 N/A$496.80 $993.60 $844.56 $1,415.88 N/A$633.53 $1,267.06 $1,077.00 $1,805.56 N/A$473.67 $947.34 $805.24 $1,349.96 N/A$485.79 $971.58 $825.84 $1,384.50 N/A$469.13 $938.26 $797.52 $1,337.02 N/A$450.95 $901.90 $766.62 $1,285.21 N/A$471.40 $942.80 $801.38 $1,343.49 N/A$575.90 $1,151.80 $979.03 $1,641.32 N/A$573.55 $1,147.10 $975.04 $1,634.62 N/A$574.33 $1,148.66 $976.36 $1,636.84 N/A$545.46 $1,090.92 $927.28 $1,554.56 N/A$675.60 $1,351.20 $1,148.52 $1,925.46 N/A$649.43 $1,298.86 $1,104.03 $1,850.88 N/A$680.51 $1,361.02 $1,156.87 $1,939.45 N/A$810.53 $1,621.06 $1,377.90 $2,310.01 N/A


$300.47 $600.94 $510.80 $856.34 N/A$308.16 $616.32 $523.87 $878.26 N/A$297.59 $595.18 $505.90 $848.13 N/A$286.05 $572.10 $486.29 $815.24 N/A$299.04 $598.08 $508.37 $852.26 N/A$365.31 $730.62 $621.03 $1,041.13 N/A$363.83 $727.66 $618.51 $1,036.92 N/A$364.33 $728.66 $619.36 $1,038.34 N/A$346.01 $692.02 $588.22 $986.13 N/A$428.56 $857.12 $728.55 $1,221.40 N/A$411.97 $823.94 $700.35 $1,174.11 N/A$431.68 $863.36 $733.86 $1,230.29 N/A$514.16 $1,028.32 $874.07 $1,465.36 N/A


$390.26 $780.52 $663.44 $1,112.24 N/A$400.23 $800.46 $680.39 $1,140.66 N/A$386.51 $773.02 $657.07 $1,101.55 N/A$371.53 $743.06 $631.60 $1,058.86 N/A$388.39 $776.78 $660.26 $1,106.91 N/A$474.47 $948.94 $806.60 $1,352.24 N/A$472.54 $945.08 $803.32 $1,346.74 N/A

Page 20



First Quarter 2015


Small vs

Individual

Standard vs


NY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 6 SyracuseNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 6 SyracuseNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 6 SyracuseNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 6 SyracuseNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 6 SyracuseNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 6 SyracuseNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 6 SyracuseNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 6 SyracuseNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 6 SyracuseNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 6 Syracuse








NY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 7 Utica/ Watertown



NY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 7 Utica/ Watertown


NY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 7 Utica/ Watertown

NY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 7 Utica/ Watertown

NY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 7 Utica/ Watertown

NY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 7 Utica/ Watertown

NY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 7 Utica/ WatertownNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 8 Long IslandNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 8 Long Island

Exhibit C


Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


$473.18 $946.36 $804.41 $1,348.56 N/A$449.41 $898.82 $764.00 $1,280.82 N/A$556.63 $1,113.26 $946.27 $1,586.40 N/A$535.06 $1,070.12 $909.60 $1,524.92 N/A$560.67 $1,121.34 $953.14 $1,597.91 N/A$667.80 $1,335.60 $1,135.26 $1,903.23 N/A


$366.30 $732.60 $622.71 $1,043.96 N/A

$375.67 $751.34 $638.64 $1,070.66 N/A

$362.77 $725.54 $616.71 $1,033.89 N/A

$348.72 $697.44 $592.82 $993.85 N/A

$364.53 $729.06 $619.70 $1,038.91 N/A

$445.34 $890.68 $757.08 $1,269.22 N/A

$443.52 $887.04 $753.98 $1,264.03 N/A

$444.13 $888.26 $755.02 $1,265.77 N/A

$421.81 $843.62 $717.08 $1,202.16 N/A

$522.45 $1,044.90 $888.17 $1,488.98 N/A

$502.20 $1,004.40 $853.74 $1,431.27 N/A

$526.25 $1,052.50 $894.63 $1,499.81 N/A

$626.79 $1,253.58 $1,065.54 $1,786.35 N/A

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

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

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

N/A N/A N/A N/A N/A$463.19 $926.38 $787.42 $1,320.09 N/A$475.04 $950.08 $807.57 $1,353.86 N/A

Page 21



First Quarter 2015


Small vs

Individual

Standard vs


NY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 8 Long IslandNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 8 Long IslandNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 8 Long IslandNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 8 Long IslandNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 8 Long IslandNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 8 Long IslandNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 8 Long IslandNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 8 Long IslandNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 8 Long IslandNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 8 Long IslandNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 8 Long IslandNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 8 Long IslandNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 8 Long IslandNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 8 Long IslandNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 8 Long Island

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 1 Albany

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 2 Buffalo

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 3 Mid-Hudson

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 4 NYC

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 5 Rochester

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 6 Syracuse

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 7 Utica/ Watertown

NY-E-100 Dependent Through Age 29 Small Non-StandardAll Metal Levels 8 Long Island

NY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 1 AlbanyNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 1 AlbanyNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 1 AlbanyNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 1 AlbanyNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 2 BuffaloNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 2 Buffalo

Exhibit C


Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


$458.75 $917.50 $779.88 $1,307.44 N/A$440.98 $881.96 $749.67 $1,256.79 N/A$460.98 $921.96 $783.67 $1,313.79 N/A$563.16 $1,126.32 $957.37 $1,605.01 N/A$560.86 $1,121.72 $953.46 $1,598.45 N/A$561.63 $1,123.26 $954.77 $1,600.65 N/A$533.41 $1,066.82 $906.80 $1,520.22 N/A$660.66 $1,321.32 $1,123.12 $1,882.88 N/A$635.06 $1,270.12 $1,079.60 $1,809.92 N/A$665.45 $1,330.90 $1,131.27 $1,896.53 N/A$792.61 $1,585.22 $1,347.44 $2,258.94 N/A


0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A

0.49% 0.49% 0.49% 0.49% N/A-$1.85 -$3.70 -$3.15 -$5.27 N/A-$2.15 -$4.30 -$3.66 -$6.13 N/A-$2.47 -$4.94 -$4.20 -$7.04 N/A-$2.77 -$5.54 -$4.71 -$7.89 N/A-$2.05 -$4.10 -$3.49 -$5.84 N/A-$2.40 -$4.80 -$4.08 -$6.84 N/A

Page 22



First Quarter 2015


Small vs

Individual

Standard vs


NY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 2 BuffaloNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 2 BuffaloNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 3 Mid-HudsonNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 3 Mid-HudsonNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 3 Mid-HudsonNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 3 Mid-HudsonNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 4 NYCNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 4 NYCNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 4 NYCNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 4 NYCNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 5 RochesterNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 5 RochesterNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 5 RochesterNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 5 RochesterNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 6 SyracuseNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 6 SyracuseNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 6 SyracuseNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 6 Syracuse

NY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 7 Utica/ Watertown

NY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 7 Utica/ Watertown

NY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 7 Utica/ Watertown

NY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 7 Utica/ WatertownNY-E-399-B Family Planning Exclusion Bronze Small Non-Standard Bronze 8 Long IslandNY-E-399-S Family Planning Exclusion Silver Small Non-Standard Silver 8 Long IslandNY-E-399-G Family Planning Exclusion Gold Small Non-Standard Gold 8 Long IslandNY-E-399-P Family Planning Exclusion Platinum Small Non-Standard Platinum 8 Long Island

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 1 Albany

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 2 Buffalo

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 3 Mid-Hudson

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 4 NYC

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 5 Rochester

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 6 Syracuse

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 7 Utica/ Watertown

NY-E-USNF Unlimited Skilled Nursing Facility Small Non-StandardAll Metal Levels 8 Long Island

Exhibit C


Single

Single +

Spouse

Single +

Child(ren)

Single +

Spouse +


-$2.73 -$5.46 -$4.64 -$7.78 N/A-$3.08 -$6.16 -$5.24 -$8.78 N/A-$2.08 -$4.16 -$3.54 -$5.93 N/A-$2.43 -$4.86 -$4.13 -$6.93 N/A-$2.77 -$5.54 -$4.71 -$7.89 N/A-$3.13 -$6.26 -$5.32 -$8.92 N/A-$2.45 -$4.90 -$4.17 -$6.98 N/A-$2.84 -$5.68 -$4.83 -$8.09 N/A-$3.25 -$6.50 -$5.53 -$9.26 N/A-$3.67 -$7.34 -$6.24 -$10.46 N/A-$1.54 -$3.08 -$2.62 -$4.39 N/A-$1.81 -$3.62 -$3.08 -$5.16 N/A-$2.06 -$4.12 -$3.50 -$5.87 N/A-$2.33 -$4.66 -$3.96 -$6.64 N/A-$2.01 -$4.02 -$3.42 -$5.73 N/A-$2.35 -$4.70 -$4.00 -$6.70 N/A-$2.68 -$5.36 -$4.56 -$7.64 N/A-$3.02 -$6.04 -$5.13 -$8.61 N/A

-$1.89 -$3.78 -$3.21 -$5.39 N/A

-$2.19 -$4.38 -$3.72 -$6.24 N/A

-$2.52 -$5.04 -$4.28 -$7.18 N/A

-$2.82 -$5.64 -$4.79 -$8.04 N/A-$2.39 -$4.78 -$4.06 -$6.81 N/A-$2.78 -$5.56 -$4.73 -$7.92 N/A-$3.19 -$6.38 -$5.42 -$9.09 N/A-$3.59 -$7.18 -$6.10 -$10.23 N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

3.00% 3.00% 3.00% 3.00% N/A

Page 23



First Quarter 2015


Small vs

Individual

Standard vs


NY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 1 AlbanyNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 1 AlbanyNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 1 AlbanyNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 1 AlbanyNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SS-004-N (2015) Non-Standard Silver 4 Off Small Non-Standard Silver 1 AlbanyNY-EPO-SG-001-N (2015) Non-Standard Gold 1 Off Small Non-Standard Gold 1 AlbanyNY-EPOH-SG-002-N (2015) Non-Standard Gold 2 Off Small Non-Standard Gold 1 AlbanyNY-EPO-SG-003-N (2015) Non-Standard Gold 3 Off Small Non-Standard Gold 1 AlbanyNY-EPO-SP-001-N (2015) Non-Standard Platinum 1 Off Small Non-Standard Platinum 1 AlbanyNY-HQNETHD-SB-001-N (2015) Non-Standard HQNet Bronze 1 Off Small Non-Standard Bronze 1 AlbanyNY-HQNETHD-SS-001-N (2015) Non-Standard HQNet Silver 1 Off Small Non-Standard Silver 1 AlbanyNY-HQNET-SG-001-N (2015) Non-Standard HQNet Gold 1 Off Small Non-Standard Gold 1 AlbanyNY-HQNET-SP-001-N (2015) Non-Standard HQNet Platinum 1 Off Small Non-Standard Platinum 1 AlbanyNY-EPO-SB-001-N (2015) Non-Standard Bronze 1 Off Small Non-Standard Bronze 2 BuffaloNY-EPO-SB-002-N (2015) Non-Standard Bronze 2 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-003-N (2015) Non-Standard Bronze 3 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-004-N (2015) Non-Standard Bronze 4 Off Small Non-Standard Bronze 2 BuffaloNY-EPOH-SB-005-N (2015) Non-Standard Bronze 5 Off Small Non-Standard Bronze 2 BuffaloNY-EPO-SS-001-N (2015) Non-Standard Silver 1 Off Small Non-Standard Silver 2 BuffaloNY-EPO-SS-002-N (2015) Non-Standard Silver 2 Off Small Non-Standard Silver 2 BuffaloNY-EPOH-SS-003-N (2015) Non-Standard Silver 3 Off

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