Silver Plan 100%-150% FPL. Member Cost Share. Member Cost Share. Member Cost Share. Deductible Applies. Deductible Applies. Deductible Applies

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1 A California Health Benefit Exchange QHP Certification Application for Plan ear Attachment B Standard Benefit Plan Design Deviation Indicate requests for deviations from the PatientCentered Benefit Plan Designs be entering alternate cost sharing for the appropriate service type. Applicant must document rationale for each requested deviation, and rationale must include reference to regulatory compliance, administrative or operational barriers to implementing the PatientCentered Benefit Plan Designs. V C a Platinum Coinsurance Plan Platinum Copay Plan Gold Coinsurance Plan Gold Copay Plan Bronze Plan 100%150% FPL 150%200% FPL 200%250% FPL Bronze Plan Bronze HDHP Plan Catastrophic Plan Rationale for benefit deviation (must reference regulatory compliance, administrative or operational barriers) Common Medical Event Service Type Primary care visit to treat an injury, illness, or condition Routine Foot Care Health care Other practitioner office visit provider s office Acupuncture or clinic visit Diabetes Education Specialist visit Allergy Testing Preventive care/ screening/ immunization Tests Drugs to treat illness or condition Laboratory Tests Xrays and Diagnostic Imaging Imaging (CT/PET scans, MRIs) Tier 1 Tier 2 Tier 3 Tier 4 Surgery facility fee (e.g., C Abortion for Which Public Funding is Prohibited (non MSP) Outpatient Bariatric Surgery Physician/surgeon fees Outpatient visit Dialysis C o Radiation Chemotherapy Infusion Therapy Emergency room combined facility and physician fee (waived if admitted) Emergency medical transportation Need immediate attention Urgent care Facility fee (e.g. hospital room) Hospital stay Transplant Reconstructive Surgery Treatment for TMJ Physician/surgeon fee Mental/Behavioral health outpatient office visits Mental/Behavioral health other outpatient items and Mental health, Mental/Behavioral health inpatient facility fee (e.g. hospital behavioral room) health, or Mental/Behavioral health inpatient physician/surgeon fee substance abuse needs Substance Use disorder outpatient office visits Substance Use disorder other outpatient items and Substance Use inpatient facility fee (e.g. hospital room) Substance use disorder inpatient physician/surgeon fee Prenatal care and preconception visits Pregnancy Delivery and all inpatient Hospital Professional Well Baby Visits Home health care Outpatient Rehabilitation Rehabilitative Speech Therapy Rehabilitative Occupational Therapy Help recovering or other special Rehabilitative Physical Therapy health needs Outpatient Habilitation Skilled nursing care Durable medical equipment Prosthetic Device Hospice service Eye exam Child eye care 1 pair of glasses per year (or contact lenses in lieu of glasses) Oral Exam Preventive Cleaning Child Dental Preventive Xray Diagnostic and Sealants per Tooth Preventive Topical Fluoride Application Space Maintainers Fixed Child Dental Amalgam Fill 1 Surface Basic Services Root Canal Molar Gingivectomy per Quad Child Dental Extraction Single Tooth Exposed Root or Erupted Major Services Extraction Complete Bony Porcelain with Metal Crown Child Medically necessary orthodontics Orthodontics See endnotes.

2 QHP Certification Application for Plan ear Attachment C1 Current & Projected Please provide the following for each product (HMO/PPO/EPO/HSP) in the individual market: 1 as of April 1, means enrollee made binder payment. Applicants not currently contracted should leave 2018 effectuated columns blank. 2 Projections. These should reflect anticipated enrollment for the Plan ear. Data submitted must be consistent with all SERFF templates and any other application submissions. Rating Region County 2018 Alpine Del Norte Siskiyou Modoc Lassen Shasta Trinity Humboldt Tehama Plumas Nevada Sierra Mendocino Lake Butte Glenn Sutter uba Colusa Amador Calaveras Tuolumne Napa Sonoma Solano Marin Sacramento Placer El Dorado olo Region 4 San Francisco Region 5 Contra Costa Region 6 Alameda Region 7 Santa Clara Region 8 San Mateo Region 9 Santa Cruz Region 9 Monterey Region 9 San Benito 0 San Joaquin 0 Stanislaus 0 Merced 0 Mariposa 0 Tulare 1 Fresno 1 Kings 1 Madera 2 San Luis Obispo 2 Ventura 2 Santa Barbara 3 Mono 3 Inyo 3 Imperial 4 Kern 5 Los Angeles 6 Los Angeles 7 San Bernardino 7 Riverside 8 Orange 9 San Diego Statewide Total HMO PPO EPO HSP

3 QHP Certification Application for Plan ear Attachment C2 California Off Exchange Please provide effectuated enrollment as of April 1, 2018 for each line of business. means enrollee made binder payment. ship for employer based coverage should be reported based on member residence address as opposed to employer location. Data submitted must be consistent with all SERFF templates and any other application submissions. Rating Region County EmployerBased Individual Market Government Payers Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 9 Region Alpine Del Norte Siskiyou Modoc Lassen Shasta Trinity Humboldt Tehama Plumas Nevada Sierra Mendocino Lake Butte Glenn Sutter uba Colusa Amador Calaveras Tuolumne Napa Sonoma Solano Marin Sacramento Placer El Dorado olo San Francisco Contra Costa Alameda Santa Clara San Mateo Santa Cruz Monterey San Benito San Joaquin Stanislaus Merced Mariposa Tulare Fresno Kings Madera San Luis Obispo Ventura Santa Barbara Mono Inyo Imperial Kern Los Angeles Los Angeles San Bernardino Riverside Orange San Diego Statewide Total CalPERS Large Group Small Group Mirrored Off Exchange NonMirrored Off Exchange Tricare MediCal Medicare

4 QHP Certification Application for Plan ear Attachment D2 Media Plan Flowchart Media Plan Costs (rounded) 3Sep 10Sep 17Sep 24Sep 1Oct 8Oct 15Oct 22Oct 29Oct 5Nov 12Nov 19Nov 26Nov 3Dec 10Dec 17Dec 24Dec 31Dec 7Jan 14Jan 21Jan 28Jan 4Feb 11Feb 18Feb Television Radio OutofHome Print (Newsprint, Magazine, Freestanding) Direct Mail Shared Mail Search Engine Marketing Digital (display, video, mobile, radio) Social media marketing Other Community Events Other Lead Purchasing *Please add weeks, if needed *Use darker color to indicate media heavy up APPLICANT NAME OE Media Plan 2018 Q4 Q1

5 QHP Certification Application for Plan ear Attachment D2 Media Plan Flowchart Media Plan Costs (rounded) 3Sep 10Sep 17Sep 24Sep 1Oct 8Oct 15Oct 22Oct 29Oct 5Nov 12Nov 19Nov 26Nov 3Dec 10Dec 17Dec 24Dec 31Dec 7Jan 14Jan 21Jan 28Jan 4Feb 11Feb 18Feb Television 20M Radio 1.5M OutofHome 1M Print (Newsprint, Magazine, Freestanding) 1M Direct Mail 1M Shared Mail 0 Search Engine Marketing 250k Digital (display, video, mobile, radio) 300k Social media 500k marketing 250k Other Community Events 200k Other Lead Purchasing 50k *Please add weeks, if needed *Use darker color to indicate media heavy up SAMPLE COMPAN NAME OE Media Plan 2018 Q4 Q1

6 QHP Certification Application for Plan ear Attachment D3 OE 6 Estimated Media Spend by Designated Market Area APPLICANT NAME OE5 Estimated Media Spend by Designated Market Area Media/Market Television Radio OutofHome Print (Newsprint, Magazine, Freestanding) Direct Mail Shared Mail Search Engine Marketing Digital (display, video, mobile, radio) Social media marketing Other Community Events Other Lead Purchasing Total Los Angeles Sacramento Stockton Modesto San FranciscoOakland San Jose San Diego Santa BarbaraSanta MariaSan Luis Obispo Palm Springs Fresno Visalia Eureka Monterey Bakersfield ChicoRedding El Centro Total