INPUT DATA: Inflation adjustment 0.0% KEY OUTPUT: PMPM bid $ 31.08 Administrative expense per. 0.0% Premium...

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INPUT DATA: Inflation adjustment 0.0% KEY OUTPUT: PMPM bid $ 31.08 Administrative expense per. 0.0% Premium rated: Profit/reserves percent 0.0% Single Family $ OTHER INPUT AND MODEL-GENERATED DATA: PMPM Calculation: Historical Historical Cost Base MPM Cost Copay Adjustment Fa Adjusted ation Adjusted PMPM PMPM Cost 1. Medical Expenses Facility Services: Inpatient: Acute Skilled nursing Mental health Substance abuse Surgical procedures Emergency room Outpatient procedures Total facility services PMPM amount Physician Services: Primary care Specialist care Office visits Surgical services All other services 0.0000 $ 0.0000 0.0000 0.0000 $ 0.0000 0.0000 0.0000 0.0000 0.0000 0.41 1.0000 1.0000 0.41 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 3.43 1.0000 1.0000 3.43 $ 3.84 $ 3.84 $ 3.84 $ 0.0000 0.0000 $ 0.0000 0.0000 9.00 23.67 0.9544 1.0000 0.8659 8.59 0.9100 18.65 $27.24 $ 27.24 $ 31.08 Total physician services PMPM amount Total facility and physician services PMPM amount II. Other Expenses Administrative Reserves Total other expenses Total PMPM amount II. Premium Rates Rate factor Monthly premium r Single Family 0.000 0.000 $0.00 $0.00 $ $ $ 31.08 INPUT DATA: Inflation adjustment 0.0% KEY OUTPUT: PMPM bid $ 31.08 Administrative expense per. 0.0% Premium rated: Profit/reserves percent 0.0% Single Family $ OTHER INPUT AND MODEL-GENERATED DATA: PMPM Calculation: Historical Historical Cost Base MPM Cost Copay Adjustment Fa Adjusted ation Adjusted PMPM PMPM Cost 1. Medical Expenses Facility Services: Inpatient: Acute Skilled nursing Mental health Substance abuse Surgical procedures Emergency room Outpatient procedures Total facility services PMPM amount Physician Services: Primary care Specialist care Office visits Surgical services All other services 0.0000 $ 0.0000 0.0000 0.0000 $ 0.0000 0.0000 0.0000 0.0000 0.0000 0.41 1.0000 1.0000 0.41 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 3.43 1.0000 1.0000 3.43 $ 3.84 $ 3.84 $ 3.84 $ 0.0000 0.0000 $ 0.0000 0.0000 9.00 23.67 0.9544 1.0000 0.8659 8.59 0.9100 18.65 $27.24 $ 27.24 $ 31.08 Total physician services PMPM amount Total facility and physician services PMPM amount II. Other Expenses Administrative Reserves Total other expenses Total PMPM amount II. Premium Rates Rate factor Monthly premium r Single Family 0.000 0.000 $0.00 $0.00 $ $ $ 31.08