Rates Table Template v2.3

To validate press Validate button or Ctrl + Shift + V. To finalize, press Finalize button or Ctrl + Shift + F. If you are a community rating state, select Family Option under Age and fill in all columns. If you are not community rating state, select 0-20 under Age and provide an Individual Rate for every age band. If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use. To add a new sheet, press the Add Sheet button, or Ctrl + Shift + S. All plans must have the same dates on a sheet.

32901 66-0555677 1/1/2017 12/31/2017

HIOS Issuer ID* Federal TIN* Rate Effective Date* Rate Expiration Date*

Plan ID*

Rating Area ID*

Required: Enter the 14-character Plan ID

Required: Select the Rating Area ID

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

TS Directo Oro (1/2017)

Rating Area 1

Tobacco*

Age*

Require: Required: Select if Tobacco use of subscriber is Select the age of a subscriber eligible used to determine if a person is eligible for the rate for a rate from a plan

Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User Tobacco User/NonTobacco User

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 and Older

Individual Rate*

Individual Tobacco Rate*

Required: Enter the rate of an Individual NonTobacco or No Preference enrollee on a plan

Required: Enter the rate of an Individual tobacco enrollee on a plan

99.45

99.45

156.61

156.61

156.61

156.61

156.61

156.61

156.61

156.61

157.23

157.23

160.36

160.36

164.12

164.12

170.23

170.23

175.24

175.24

177.75

177.75

181.51

181.51

185.27

185.27

187.61

187.61

190.12

190.12

191.37

191.37

192.63

192.63

193.88

193.88

195.13

195.13

197.64

197.64

200.14

200.14

203.90

203.90

207.50

207.50

212.51

212.51

218.78

218.78

226.14

226.14

234.91

234.91

244.78

244.78

256.05

256.05

267.17

267.17

279.70

279.70

292.07

292.07

305.70

305.70

319.48

319.48

334.35

334.35

349.23

349.23

365.36

365.36

381.65

381.65

399.03

399.03

407.65

407.65

425.03

425.03

440.06

440.06

449.93

449.93

462.30

462.30

469.82

469.82