HEALTHFIRST PHSP, INC. Rate Manual Pursuant to New York ......Rate Manual Pursuant to New York Insurance Law Section 4308(c) Individual HMO Rates and Forms Submission Effective January

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HEALTHFIRST PHSP, INC.

Rate Manual Pursuant to New York Insurance Law Section 4308(c)

Individual HMO Rates and Forms Submission

Effective January 1, 2021

_____________________________________________________________________________________ Healthfirst PHSP, Inc. 2021 Rate Manual; Individual Market Page 2 of 31

TABLE OF CONTENTS

I. On-Exchange Individual Plan Rates………………………………………………………………………………… 3 A. New York City rating region (#4) rates…………………………………………………….……….……... 4

B. Long Island rating region (#8) rates………………….…………………………….……….……………... 7

II. Off-Exchange Individual Plan Rates………………………………………………………………………………… 10 A. New York City rating region (#4) rates…..……………………………………….………………………... 11

B. Long Island rating region (#8) rates………………….…………………………….………...……………....14

III. Rating Factors, Rate Calculations, Loss Ratios, and Commissions/Fees………………………….17

IV. Description of Benefits, Types of Coverage, Limitations, & Exclusions…………………………..22

A. Healthfirst Standard Benefit Descriptions (On & Off Exchange)………………….…..………... 23

B. Healthfirst Non-Standard Plans Benefit Descriptions (On & Off Exchange)...…………….. 26

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SECTION I

On-Exchange Individual HMO Plan Rates

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Section I.A – Rate Pages: On-Exchange Standard & Non-Standard Plans –Rating Region #4

HEALTHFIRST PHSP, INC. ON-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS

RATE PAGES - EFFECTIVE JANUARY 1, 2021 AREA: New York City Rating Region (NEW YORK, KINGS, QUEENS, RICHMOND, BRONX, WESTCHESTER, & ROCKLAND COUNTIES) –

Rating Region #4

Platinum

Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-PSOB-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Platinum Leaf 91237NY0020015 Standard, Age 26 $929.26 $1,858.52 $1,579.74 $2,648.39

Healthfirst Platinum Leaf, Age 29 Rider 91237NY0020016 Standard, Age 29 $938.55 $1,877.10 $1,595.54 $2,674.87

Healthfirst Platinum Leaf Premier 91237NY0020058 Non-Standard, Age 26 $961.61 $1,923.22 $1,634.74 $2,740.59

Healthfirst Platinum Leaf Premier, Age 29 Rider 91237NY0020059 Non-Standard, Age 29 $971.22 $1,942.44 $1,651.07 $2,767.98

One Child

Two Children

Three or More

Healthfirst Platinum Leaf Child-Only 91237NY0020026 Child-Only $382.86 $765.72 $1,148.58

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Gold

Applicable Form Numbers: HF-STDIND-21, HF-GSOB-21, HF-GSOBNS-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Gold Leaf 91237NY0020011 Standard, Age 26 $738.27 $1,476.54 $1,255.06 $2,104.07

Healthfirst Gold Leaf, Age 29 Rider 91237NY0020012 Standard, Age 29 $745.63 $1,491.26 $1,267.57 $2,125.05

Healthfirst Gold Leaf Premier 91237NY0020056 Non-Standard, Age 26 $771.23 $1,542.46 $1,311.09 $2,198.01

Healthfirst Gold Leaf Premier, Age 29 Rider 91237NY0020057 Non-Standard, Age 29 $778.94 $1,557.88 $1,324.20 $2,219.98

One Child Two Children

Three or More

Healthfirst Gold Leaf Child-Only 91237NY0020024 Child-Only $304.17 $608.34 $912.51

Silver

Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-SSOB-21, HF-SSOBNS-21, HF-S200SOB-21, HF-S200SOBNS-21, HF-S150SOB-21,

HF-S100SOB-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Silver Leaf 91237NY0020007 Standard, Age 26 $611.17 $1,222.34 $1,038.99 $1,741.83

Healthfirst Silver Leaf, Age 29 Rider 91237NY0020008 Standard, Age 29 $617.29 $1,234.58 $1,049.39 $1,759.28

Healthfirst Silver Leaf Premier 91237NY0020054 Non-Standard, Age 26 $636.70 $1,273.40 $1,082.39 $1,814.60

Healthfirst Silver Leaf Premier, Age 29 Rider 91237NY0020055 Non-Standard, Age 29 $643.08 $1,286.16 $1,093.24 $1,832.78

One Child

Two Children Three or

More

Healthfirst Silver Leaf Child-Only 91237NY0020022 Child-Only $251.81 $503.62 $755.43

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Bronze

Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-BSOB-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Bronze Leaf 91237NY0020003 Standard, Age 26 $457.26 $914.52 $777.34 $1,303.19

Healthfirst Bronze Leaf, Age 29 Rider 91237NY0020004 Standard, Age 29 $461.81 $923.62 $785.08 $1,316.16

Healthfirst Bronze Leaf Premier 91237NY0020052 Non-Standard, Age 26 $473.15 $946.30 $804.36 $1,348.48

Healthfirst Bronze Leaf Premier, Age 29 Rider 91237NY0020053 Non-Standard, Age 29 $477.90 $955.80 $812.43 $1,362.02

One Child

Two Children

Three or More

Healthfirst Bronze Leaf Child-Only 91237NY0020020 Child-Only $188.38 $376.76 $565.14

Catastrophic

Applicable Form Numbers: HF-STDCC-21, HF-CCSOB-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Green Leaf 91237NY0020018 Standard, Age 26 $282.07 $564.14 $479.52 $803.90

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Section I.B – Rate Pages: On-Exchange Standard & Non-Standard Plans –Rating Region #8

HEALTHFIRST PHSP, INC. ON-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS

RATE PAGES - EFFECTIVE JANUARY 1, 2021 AREA: Long Island Rating Region (NASSAU & SUFFOLK COUNTIES) – Rating Region #8

Platinum

Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-PSOB-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Platinum Leaf 91237NY0020015 Standard, Age 26 $929.26 $1,858.52 $1,579.74 $2,648.39

Healthfirst Platinum Leaf, Age 29 Rider 91237NY0020016 Standard, Age 29 $938.55 $1,877.10 $1,595.54 $2,674.87

Healthfirst Platinum Leaf Premier 91237NY0020058 Non-Standard, Age 26 $961.61 $1,923.22 $1,634.74 $2,740.59

Healthfirst Platinum Leaf Premier, Age 29 Rider 91237NY0020059 Non-Standard, Age 29 $971.22 $1,942.44 $1,651.07 $2,767.98

One Child

Two Children

Three or More

Healthfirst Platinum Leaf Child-Only 91237NY0020026 Child-Only $382.86 $765.72 $1,148.58

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Gold

Applicable Form Numbers: HF-STDIND-21, HF-GSOB-21, HF-GSOBNS-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Gold Leaf 91237NY0020011 Standard, Age 26 $738.27 $1,476.54 $1,255.06 $2,104.07

Healthfirst Gold Leaf, Age 29 Rider 91237NY0020012 Standard, Age 29 $745.63 $1,491.26 $1,267.57 $2,125.05

Healthfirst Gold Leaf Premier 91237NY0020056 Non-Standard, Age 26 $771.23 $1,542.46 $1,311.09 $2,198.01

Healthfirst Gold Leaf Premier, Age 29 Rider 91237NY0020057 Non-Standard, Age 29 $778.94 $1,557.88 $1,324.20 $2,219.98

One Child

Two Children

Three or More

Healthfirst Gold Leaf Child-Only 91237NY0020024 Child-Only $304.17 $608.34 $912.51

Silver

Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-SSOB-21, HF-SSOBNS-21, HF-S200SOB-21, HF-S200SOBNS-21, HF-S150SOB-21,

HF-S100SOB-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Silver Leaf 91237NY0020007 Standard, Age 26 $611.17 $1,222.34 $1,038.99 $1,741.83

Healthfirst Silver Leaf, Age 29 Rider 91237NY0020008 Standard, Age 29 $617.29 $1,234.58 $1,049.39 $1,759.28

Healthfirst Silver Leaf Premier 91237NY0020054 Non-Standard, Age 26 $636.70 $1,273.40 $1,082.39 $1,814.60

Healthfirst Silver Leaf Premier, Age 29 Rider 91237NY0020055 Non-Standard, Age 29 $643.08 $1,286.16 $1,093.24 $1,832.78

One Child

Two Children Three or More

Healthfirst Silver Leaf Child-Only 91237NY0020022 Child-Only $251.81 $503.62 $755.43

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Bronze

Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-BSOB-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Bronze Leaf 91237NY0020003 Standard, Age 26 $457.26 $914.52 $777.34 $1,303.19

Healthfirst Bronze Leaf, Age 29 Rider 91237NY0020004 Standard, Age 29 $461.81 $923.62 $785.08 $1,316.16

Healthfirst Bronze Leaf Premier 91237NY0020052 Non-Standard, Age 26 $473.15 $946.30 $804.36 $1,348.48

Healthfirst Bronze Leaf Premier, Age 29 Rider 91237NY0020053 Non-Standard, Age 29 $477.90 $955.80 $812.43 $1,362.02

One Child

Two Children

Three or More

Healthfirst Bronze Leaf Child-Only 91237NY0020020 Child-Only $188.38 $376.76 $565.14

Catastrophic

Applicable Form Numbers: HF-STDCC-21, HF-CCSOB-21, HF-NoCSSOB-21

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Green Leaf 91237NY0020018 Standard, Age 26 $282.07 $564.14 $479.52 $803.90

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SECTION II

Off-Exchange Individual HMO Plan Rates

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Section II.A – Rate Pages: Off-Exchange Standard Plans –Rating Region #4

HEALTHFIRST PHSP, INC. OFF-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS

RATE PAGES - EFFECTIVE JANUARY 1, 2021 AREA: New York City Rating Region (NEW YORK, KINGS, QUEENS, RICHMOND, BRONX, WESTCHESTER, & ROCKLAND COUNTIES) –

Rating Region #4

Platinum

Applicable Form Numbers: HF-STDIND-21-OFF, HF-PSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO A 91237NY0020039 Standard, Age 26 $929.26 $1,858.52 $1,579.74 $2,648.39

Healthfirst HMO A, Age 29 Rider 91237NY0020040 Standard, Age 29 $938.55 $1,877.10 $1,595.54 $2,674.87

Healthfirst HMO A-VAD 91237NY0020067 Non-Standard, Age 26 $961.61 $1,923.22 $1,634.74 $2,740.59

Healthfirst HMO A-VAD, Age 29 Rider 91237NY0020068 Non-Standard, Age 29 $971.22 $1,942.44 $1,651.07 $2,767.98

One Child

Two Children

Three or More

Healthfirst HMO A Child-Only 91237NY0020049 Child-Only $382.86 $765.72 $1,148.58

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Gold

Applicable Form Numbers: HF-STDIND-21-OFF, HF-GSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO B 91237NY0020035 Standard, Age 26 $738.27 $1,476.54 $1,255.06 $2,104.07

Healthfirst HMO B, Age 29 Rider 91237NY0020036 Standard, Age 29 $745.63 $1,491.26 $1,267.57 $2,125.05

Healthfirst HMO B-VAD 91237NY0020065 Non-Standard, Age 26 $771.23 $1,542.46 $1,311.09 $2,198.01

Healthfirst HMO B-VAD, Age 29 Rider 91237NY0020066 Non-Standard, Age 29 $778.94 $1,557.88 $1,324.20 $2,219.98

One Child

Two Children

Three or More

Healthfirst HMO B Child-Only 91237NY0020047 Child-Only $304.17 $608.34 $912.51

Silver

Applicable Form Numbers: HF-STDIND-21-OFF, HF-SSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO C 91237NY0020031 Standard, Age 26 $611.17 $1,222.34 $1,038.99 $1,741.83

Healthfirst HMO C, Age 29 Rider 91237NY0020032 Standard, Age 29 $617.29 $1,234.58 $1,049.39 $1,759.28

Healthfirst HMO C-VAD 91237NY0020063 Non-Standard, Age 26 $636.70 $1,273.40 $1,082.39 $1,814.60

Healthfirst HMO C-VAD, Age 29 Rider 91237NY0020064 Non-Standard, Age 29 $643.08 $1,286.16 $1,093.24 $1,832.78

One Child

Two Children

Three or More

Healthfirst HMO C Child-Only 91237NY0020045 Child-Only $251.81 $503.62 $755.43

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Bronze

Applicable Form Numbers: HF-STDIND-21-OFF, HF-BSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO D 91237NY0020027 Standard, Age 26 $457.26 $914.52 $777.34 $1,303.19

Healthfirst HMO D, Age 29 Rider 91237NY0020028 Standard, Age 29 $461.81 $923.62 $785.08 $1,316.16

Healthfirst HMO D-VAD 91237NY0020061 Non-Standard, Age 26 $473.15 $946.30 $804.36 $1,348.48

Healthfirst HMO D-VAD, Age 29 Rider 91237NY0020062 Non-Standard, Age 29 $477.90 $955.80 $812.43 $1,362.02

One Child

Two Children

Three or More

Healthfirst HMO D Child-Only 91237NY0020043 Child-Only $188.38 $376.76 $565.14

Catastrophic

Applicable Form Numbers: HF-STDCC-21-OFF, HF-CCSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO E 91237NY0020069 Standard, Age 26 $282.07 $564.14 $479.52 $803.90

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Section II.B – Rate Pages: Off-Exchange Standard & Non-Standard Plans –Rating Region #8

HEALTHFIRST PHSP, INC. OFF-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS

RATE PAGES - EFFECTIVE JANUARY 1, 2021 AREA: Long Island Rating Region (NASSAU & SUFFOLK COUNTIES) - Rating Region #8

Platinum

Applicable Form Numbers: HF-STDIND-21-OFF, HF-PSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO A 91237NY0020039 Standard, Age 26 $929.26 $1,858.52 $1,579.74 $2,648.39

Healthfirst HMO A, Age 29 Rider 91237NY0020040 Standard, Age 29 $938.55 $1,877.10 $1,595.54 $2,674.87

Healthfirst HMO A-VAD 91237NY0020067 Non-Standard, Age 26 $961.61 $1,923.22 $1,634.74 $2,740.59

Healthfirst HMO A-VAD, Age 29 Rider 91237NY0020068 Non-Standard, Age 29 $971.22 $1,942.44 $1,651.07 $2,767.98

One Child

Two Children

Three or More

Healthfirst HMO A Child-Only 91237NY0020049 Child-Only $382.86 $765.72 $1,148.58

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Gold

Applicable Form Numbers: HF-STDIND-21-OFF, HF-GSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO B 91237NY0020035 Standard, Age 26 $738.27 $1,476.54 $1,255.06 $2,104.07

Healthfirst HMO B, Age 29 Rider 91237NY0020036 Standard, Age 29 $745.63 $1,491.26 $1,267.57 $2,125.05

Healthfirst HMO B-VAD 91237NY0020065 Non-Standard, Age 26 $771.23 $1,542.46 $1,311.09 $2,198.01

Healthfirst HMO B-VAD, Age 29 Rider 91237NY0020066 Non-Standard, Age 29 $778.94 $1,557.88 $1,324.20 $2,219.98

One Child

Two Children

Three or More

Healthfirst HMO B Child-Only 91237NY0020047 Child-Only $304.17 $608.34 $912.51

Silver

Applicable Form Numbers: HF-STDIND-21-OFF, HF-SSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO C 91237NY0020031 Standard, Age 26 $611.17 $1,222.34 $1,038.99 $1,741.83

Healthfirst HMO C, Age 29 Rider 91237NY0020032 Standard, Age 29 $617.29 $1,234.58 $1,049.39 $1,759.28

Healthfirst HMO C-VAD 91237NY0020063 Non-Standard, Age 26 $636.70 $1,273.40 $1,082.39 $1,814.60

Healthfirst HMO C-VAD, Age 29 Rider 91237NY0020064 Non-Standard, Age 29 $643.08 $1,286.16 $1,093.24 $1,832.78

One Child

Two Children

Three or More

Healthfirst HMO C Child-Only 91237NY0020045 Child-Only $251.81 $503.62 $755.43

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Bronze

Applicable Form Numbers: HF-STDIND-21-OFF, HF-BSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO D 91237NY0020027 Standard, Age 26 $457.26 $914.52 $777.34 $1,303.19

Healthfirst HMO D, Age 29 Rider 91237NY0020028 Standard, Age 29 $461.81 $923.62 $785.08 $1,316.16

Healthfirst HMO D-VAD 91237NY0020061 Non-Standard, Age 26 $473.15 $946.30 $804.36 $1,348.48

Healthfirst HMO D-VAD, Age 29 Rider 91237NY0020062 Non-Standard, Age 29 $477.90 $955.80 $812.43 $1,362.02

One Child

Two Children

Three or More

Healthfirst HMO D Child-Only 91237NY0020043 Child-Only $188.38 $376.76 $565.14

Catastrophic

Applicable Form Numbers: HF-STDCC-21-OFF, HF-CCSOB-21-OFF

Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst HMO E 91237NY0020069 Standard, Age 26 $282.07 $564.14 $479.52 $803.90

SECTION III

Rating Factors, Rate Calculations, Loss Ratios, & Commissions/Fees

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Section III.A – Description of Rating Classes, Factors, & Premium Discounts

Census Tiers Cost Factor

Single 1.000

Single + Spouse 2.000

Single + Child(ren) 1.700

Single + Spouse + Child(ren) 2.850

Child Only 0.412

Rating Region Counties Included Area Factor

New York City (#4) Bronx, Kings, New York, Queens, Richmond,

Westchester, Rockland

1.000

Long Island (#8) Nassau, Suffolk 1.000

Dependent Age Limit Cost Factor

26 1.000

29 1.010

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Section III.B – Rate Calculation Example

Healthfirst premium rates are developed in accordance with New York’s community rating law, and

without any discounts or surcharge factors. Healthfirst’s plans are offered in Rating Regions 4 (NYC) & 8

(Long Island).

EXAMPLE:

Consumer Profile:

• Census Tier: A single, individual subscriber

• Residence: Richmond County (New York City Rating Region #4)

• Plan: Healthfirst Gold Leaf Standard Plan, not choosing the Age 29 Rider.

Rate look-up solution:

One would proceed to page 5 and refer to the table listing Gold-level plans. Next, one would refer to the row labeled, “Healthfirst Gold Leaf” and cross-reference the row labeled, “Single.” The rate for this plan is $775.17 per month.

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Section III.C – Expected Loss Ratios

The projected loss ratio using the Federal medical loss ratio (MLR) methodology is 84.9%. The expected

loss ratio under New York State’s MLR methodology is 83.5%.

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Section III.D – Broker/Agent Commissions & Fees

The products and plans listed herein do not include any consideration related to broker/agent

commissions and/or fees. Brokers/agents who sell these products and plans, accordingly, will not be

compensated by Healthfirst for such sale.

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SECTION IV

Description of Benefits, Types of Coverage, Limitations, Exclusions, Issue Limits,

& Renewal Conditions

*Note: the standard benefit description grid applies to all standard individual on- and off-exchange plans.

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Section III. A – Healthfirst Standard Plans Benefit Description (On & Off Exchange)

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Section III. B – 2021 Non-Standard Plan Benefit Descriptions (On- and Off-Exchange)

Platinum Leaf Premier/HMO A VAD Gold Leaf Premier/HMO B VAD

Individual Deductible $0 $900

Max Out of Pocket (Individual)

$2,000 $6,000

Primary Care Doctor Visit $10 copayment $20 copayment

Specialist Doctor Visit $40 copayment $40 copayment after deductible

Emergency Room (Cost sharing waived if admitted)

$100 copayment $175 copayment after deductible

Ambulatory Surgical Center Facility Fee

$100 copayment $100 copayment after deductible

Lab Diagnostic Office: PCP -$10 copayment SPC -$40 copayment Outpatient Hospital Services: $40 copayment

Office: PCP - $20 copayment SPC -$40 copayment Outpatient Hospital Services: $40 copayment

Inpatient Hospital Services [and Birthing Center]

$500 copayment per admission $1,000 copayment after deductible per Admission

Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)

$25 copayment $30 copayment after deductible

Skilled Nursing Facility 200 days per plan year

$500 copayment per admission $1,000 copayment after deductible per Admission

Inpatient Habilitation Services (Physical, Speech & Occupational therapy)

$500 copayment per admission $1,000 copayment after deductible per Admission

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Platinum Leaf Premier/HMO A VAD Gold Leaf Premier/HMO B VAD

Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)

$500 copayment per admission $1,000 copayment after deductible per Admission

Mental Health/Substance Abuse - Inpatient

$500 copayment per admission $1,000 copayment after deductible per Admission

Mental Health/Substance Abuse - Outpatient / Behavioral Health

$10 copayment $20 copayment

Retail Generic Drugs (Tier 1) $5 copayment $7 copayment

Retail Preferred Drugs (Tier 2) $50 copayment $50 copayment

Retail Non-Preferred Drugs (Tier 3) $85 copayment $100 copayment

Silver Leaf Premier/HMO C VAD Silver Leaf 200‐250 Premier

Individual Deductible $4,650 $3,500

Max Out of Pocket (Individual)

$8,700 $8,500

Primary Care Doctor Visit $30 copayment $30 copayment

Specialist Doctor Visit $55 copayment after deductible $55 copayment after deductible

Emergency Room (Cost sharing waived if admitted)

$250 copayment after deductible $250 copayment after deductible

Ambulatory Surgical Center Facility Fee

$100 copayment after deductible $100 copayment after deductible

Lab Diagnostic Office: PCP - $30 copayment SPC -$55 copayment Outpatient Hospital Services: $55 copayment

Office: PCP - $30 copayment SPC -$55 copayment Outpatient Hospital Services: $55 copayment

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Silver Leaf Premier/HMO C VAD Silver Leaf 200‐250 Premier

Inpatient Hospital Services [and Birthing Center]

$1,500 copayment after deductible per admission

$1,500 copayment after deductible per admission

Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)

$55 copayment after deductible $55 copayment after deductible

Skilled Nursing Facility 200 days per plan year

$1,500 copayment after deductible per admission

$1,500 copayment after deductible per admission

Inpatient Habilitation Services (Physical, Speech & Occupational therapy)

$1,500 copayment after deductible per admission

$1,500 copayment after deductible per admission

Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)

$1,500 copayment after deductible per admission

$1,500 copayment after deductible per admission

Mental Health/Substance Abuse - Inpatient

$1,500 copayment after deductible per admission

$1,500 copayment after deductible per admission

Mental Health/Substance Abuse - Outpatient / Behavioral Health

$30 copayment $30 copayment

Retail Generic Drugs (Tier 1) $10 copayment $10 copayment

Retail Preferred Drugs (Tier 2) $55 copayment $55 copayment

Retail Non-Preferred Drugs (Tier 3) $100 copayment $100 copayment

Bronze Leaf Premier/HMO B VAD Native American CSR Premier

(all Metal Levels)

Individual Deductible $5,150 $0

Max Out of Pocket (Individual)

$8,550 $0

____________________________________________________________________________________ Healthfirst PHSP, Inc. 2021 Rate Manual; Individual Market Page 29 of 31

Bronze Leaf Premier/HMO B VAD Native American CSR Premier

(all Metal Levels)

Primary Care Doctor Visit $45 copayment Covered in full

Specialist Doctor Visit 65% Coinsurance after deductible Covered in full

Emergency Room (Cost sharing waived if admitted)

65% Coinsurance after deductible Covered in full

Ambulatory Surgical Center Facility Fee

65% Coinsurance after deductible Covered in full

Lab Diagnostic 65% Coinsurance after deductible Covered in full

Inpatient Hospital Services [and Birthing Center]

65% Coinsurance after deductible Covered in full

Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)

65% Coinsurance after deductible Covered in full

Skilled Nursing Facility 200 days per plan year

65% Coinsurance after deductible Covered in full

Inpatient Habilitation Services (Physical, Speech & Occupational therapy)

65% Coinsurance after deductible Covered in full

Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)

65% Coinsurance after deductible Covered in full

Mental Health/Substance Abuse - Inpatient

65% Coinsurance after deductible Covered in full

Mental Health/Substance Abuse - Outpatient / Behavioral Health

$45 copayment Covered in full

Retail Generic Drugs (Tier 1) $8 copayment after deductible Covered in full

____________________________________________________________________________________ Healthfirst PHSP, Inc. 2021 Rate Manual; Individual Market Page 30 of 31

Bronze Leaf Premier/HMO B VAD Native American CSR Premier

(all Metal Levels)

Retail Preferred Drugs (Tier 2) $60 copayment after deductible Covered in full

Retail Non-Preferred Drugs (Tier 3) $95 copayment after deductible Covered in full