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SERFF Tracking #:MPHP-133206955State Tracking #:2022050055Company Tracking #:State:New YorkTOI/Sub-TOI:HOrg02G Group Health Organizations - Health Maintenance (HMO)/HOrg02G.003C Large Group Only - HMOFiling Company:MetroPlus Health PlanProduct Name:Goldcare Rate AdjustmentProject Name/Number:/Item Status:Status Date:Bypassed - Item:Bypass Reason:Attachment(s):Item Status:Status Date:Standard Exhibit 4 - Part D - Summary of Proposed Percentage Rate ChangesNot a rolling rate structure and no drug rider.Satisfied - Item:Comments:Standard Exhibit 5 - Part A - Distribution of Contracts Affected by Proposed Rate AdjustmentsAttachment(s):MetroPlus GoldCare PA Standard Exhibit 5 2022.pdfMetroPlus GoldCare PA Standard Exhibit 5 2022.xlsItem Status:Status Date:Bypassed - Item:Bypass Reason:Attachment(s):Item Status:Status Date:Standard Exhibit 5 - Part B - Distribution of Contracts Affected by Proposed Rate AdjustmentsNot a rolling rate structureSatisfied - Item:Comments:Standard Exhibit 6 - Summary of Policy Form and Product ChangesAttachment(s):MetroPlus GoldCare PA Standard Exhibit 6 2022.pdfMetroPlus GoldCare PA Standard Exhibit 6 2022.xlsItem Status:Status Date:Satisfied - Item:Comments:Standard Exhibit 7 - Historical DataAttachment(s):MetroPlus GoldCare PA Standard Exhibit 7 2022.pdfMetroPlus GoldCare PA Standard Exhibit 7 2022.xlsItem Status:Status Date:Satisfied - Item:Comments:Unified Rate Review TemplatePDF Pipeline for SERFF Tracking Number MPHP-133206955 Generated 07/07/2022 11:25 AM

SERFF Tracking #:MPHP-133206955State Tracking #:2022050055Company Tracking #:State:New YorkTOI/Sub-TOI:HOrg02G Group Health Organizations - Health Maintenance (HMO)/HOrg02G.003C Large Group Only - HMOProduct Name:Goldcare Rate AdjustmentProject Name/Number:/Attachment(s):Filing Company:MetroPlus Health PlanMetroPlus GoldCare URRT 2022.pdfPY2022 URRT 5.3.xlsmItem Status:Status Date:PDF Pipeline for SERFF Tracking Number MPHP-133206955 Generated 07/07/2022 11:25 AM

Date Contact Name Group Name Address City State ZIP Re: Notice of Premium Rate Change Group Name, Tier Name Dear Name :MetroPlus Health Plan has gained approval from the New York State Department of Financial Services(DFS) to change your premium rate for the plan year starting October 1, 2022. New York insurance lawrequires us to send you final rate information at least 60 days before your renewal date. The new amountswill apply starting on October 1, 2022.Premium rate changeNew rate increase/decrease GoldCare IGoldCare II amount % amount %We try to provide the most accurate information we can. The actual rate may change based on: the final design of plan benefits other features chosen when your plan is renewed, and any changes by DFS to the proposed rate.Based on your employer’s contribution, your out-of-pocket costs may also change.Why we have changed our ratesMetroPlusHealth works to keep its rates fair. We compare what we charge (our rates) with what we pay tomanage members’ health care needs. The things we do to lower costs help us bring you the same qualityhealth insurance in the new plan year with the approved increase decrease in rates.To learn moreYou can contact us to learn more about this change:MetroPlus Health Plan50 Water St.New York, NY 10004877.475.3795 (TTY: 711)If you need help because your hearing and/or speech are impaired, please call TTY: 711. If you need them,you can get oral interpretation and written materials in other languages.MBR 22.156FRL GC 2023 v1

You may view a plain-English summary that explains our new rates at: metroplus.org or dfs.ny.gov/consumers/health insurance/health insurance premiumsSincerely,MetroPlus Health Plan

Date Contact Name Group Name Address City State ZIP Re: Notice of Proposed Premium Rate Change Group Name, Tier Name Dear Name :MetroPlus Health Plan is asking the New York State Department of Financial Services (DFS) to okay newpremium rates for the plan year that starts on October 1, 2022. Based on New York insurance law: we must let you know when we ask DFS for premium rate changes, and DFS must review our requested changes.DFS may approve, modify, or disapprove the requested changes.Proposed premium ratesHere are the proposed changes to the plan premium:New rate increase decrease GoldCare IGoldCare II amount % amount %We estimated these amounts. The actual rates may change based on: the final design of plan benefits other features chosen when your plan is renewed, and any changes by DFS to the proposed rate.Based on your employer’s contribution, your out-of-pocket costs may also change.Why we are asking for a rate changeMetroPlusHealth works to keep its rates fair. We compare what we charge (our rates) to what we pay tomanage members’ health care needs. The things we do to lower costs help us bring you the same qualityhealth insurance in the new plan year with the increase decrease in rates we have asked for.To learn moreYou can learn more about why we have asked for a premium rate change. You may view a plain-Englishsummary of our proposed new rates at: metroplus.org or dfs.ny.gov/consumers/health insurance/health insurance premiumsMBR 22.155PRL GC 2023 v1

You can also contact us or the DFS to learn more:MetroPlus Health Plan50 Water St.New York, NY 10004877.475.3795 (TTY: 711)NYS Department of Financial ServicesHealth Bureau – Premium Rate AdjustmentsOne Commerce PlazaAlbany, NY 12257To submit a commentYou may also send comments to us or the DFS. You must do so within 30 days from the date of this notice.To submit comments to DFS, visit mment. You willneed to include: the name of your insurer the name of your plan whether you have individual or group coverageThe comments you submit will be posted on the DFS website without your personal information.Notice of approved premium rateAfter DFS approves the final plan premium rate, you will receive final rate information at least 60 daysbefore your renewal date.Sincerely,MetroPlus Health Plan

MetroPlus Health PlanSERFF Number:MPHP- 133206955Large Group - GoldCare PolicyActuarial MemorandumRate Adjustment Effective 10/1/20223/31/22

Organization Name: MetroPlus Health Plan Inc.SERFF Number: SERFF Number: MPHP- 133206955Policy Form: 01 MPGC 2023Effective Date: 10/1/2022Product NarrativeMetroPlus Health Plan Inc. (MetroPlus), a wholly-owned subsidiary of the New York CityHealth Hospitals Corporation (H H), is filing a rate adjustment of its large groupGoldCare policy pursuant to Section 4308(c).H H is the largest public health system in the United States. The mission of H H is toserve all residents of NYC without regard to one’s ability to pay. MetroPlus, in operationsince 1985, is a Prepaid Health Services Plan (PHSP) certified under Section 4403-a ofthe New York State Public Health Law. The Plan’s mission is to provide a caring, highquality customer experience to preserve and improve the health and lives of NewYorkers with our integrated healthcare system. To fulfill its mission, MetroPlus offersgovernment sponsored and other products, including: Medicaid, Child Health Plus,Medicare Advantage, HARP, Managed Long-Term Care (MLTC), Essential Plan, andIndividual Health Exchange plans. MetroPlus currently serves over 600,000 NYCresidents.Marketing efforts focus within the H H Network which includes over 11 acute andcommunity hospitals and 5 rehabilitation and residential nursing facilities. H H hasnumerous clinics throughout NYC. MetroPlus also contracts with “CommunityProviders,” physicians who are based within the communities that H H serves. Thesephysicians expand coverage options and offer primary and specialty care services tobeneficiaries in a local setting.Aside from contracting with H H and its physicians, MetroPlus also contracts with otherproviders within NYC, including contracts for specialty inpatient services, DME, vision,dental, home care, radiology, and pharmacy. The purpose is to ensure that there issufficient capacity within the MetroPlus network to serve all its beneficiaries in a timelyand convenient fashion.MetroPlus introduced the Large Group GoldCare Policy effective 12/1/2016, primarily toaccommodate the needs of the Day Care Council Local 205 DC 1707 Welfare Fund.The policy currently has six benefit options, GoldCare I, GoldCare Ia, GoldCare Ib,GoldCare II, GoldCare IIa, and GoldCare IIb with distinct benefits and providernetworks, as summarized in Attachment I. The options are as follows: Members selecting GoldCare I, GoldCare Ia, or GoldCare Ib seek care through alimited network of primarily H H providers.GoldCare II, GoldCare IIa, or GoldCare IIb allows members to seek care from alarger network, consistent with MetroPlus’ broader provider network. Out-of-networkcoverage is limited to emergency care only for both plans.All GoldCare members are currently enrolled in either GoldCare Ia or GoldCare IIa.

MetroPlus Health Plan Inc.SERFF Number: MPHP- 133206955Page 2Why the Need For a Rate AdjustmentMetroPlus is requesting no rate action, effective 10/1/2022, for its GoldCare LargeGroup product due to favorable plan experience and a reduction in administrativeexpenses.The rate adjustment will affect 1 policyholder with 1,750 membersRating MethodologyPremium rates are developed in Exhibit 1. Our rating methodology is described below.Experience, Credibility, and Manual Rate Development:GoldCare, which currently covers 1,750 employees of the Day Care Council Local205 DC 1707 Welfare Fund, was first effective 12/1/2016.Consistent with prior rate filings, we set the base period as a blend of the most recenttwo calendar years of experience. Base period claims for this filing are 24 months ofclaim experience (1/1/2020 – 12/31/2021). However, also consistent with last year’sfiling, we excluded April and May, 2020 Medical (non-Drug) claims because theywere unusually “light” due to COVID-19. We projected each year to the rating period(using trend factors described in the Supporting Details section) and weighted theresults equally.We blended the trended experience rate and added in the projected cost of GME fora composite claim rate of 426.56.GoldCare I and GoldCare IIGoldCare I (I, Ia, Ib) and GoldCare II (II, IIa, IIb) have distinct benefits and providernetworks, as summarized in Attachment I.Network Differences:GoldCare I and GoldCare II have separate provider networks. Membersselecting GoldCare I need to seek coverage primarily from H H providers. TheGoldCare II plan has a broader network consistent with Medicaid coverage –which includes many non-H H facilities. Out-of-network coverage is limited toemergency care only for both products.The reimbursement and network differential is maintained at 18%, consistentwith past pricing, as claim experience by plan is not credible.

MetroPlus Health Plan Inc.SERFF Number: MPHP- 133206955Page 3Projected Claim Cost:The composite projected claim cost PMPM of GoldCare Ia and GoldCare IIa is 426.56 PMPM.It is calculated as: Blended Experience x trend x plan change adjustment GME.Non-Benefit ExpensesAdministrative Expenses: MetroPlus’ budget for GoldCare administrative expensesfor compensation, benefits, and operational expenses for the rating period is 0.6million, or 28.24 PMPM.We did not project MetroPlus will incur administrative expenses for activities specificallydesigned to improve health care quality.We assumed MetroPlus will not use any brokers and therefore did not include anyprovision for commissions.As a non-profit Prepaid Health Service Plan, MetroPlus is exempt from the following fees: Federal Insurer fee;State premium taxes (including MTA surcharges); andFederal and state income taxes.Regulatory Fees: We reflected the following regulatory fees: 332 Assessment: We assumed the assessment would be 1% of premium.PCORI fee of 0.22 PMPMProfit Margin: We assumed after tax profit margin of 2.8% of gross premium. It isintended to fund state reserve requirements, operating reserve requirements, andcontinued investments in plan operations.MetroPlus follows NYS Department of Health Statutory Reserve Requirements as well asthe Contingent reserve requirements. As a wholly owned subsidiary of the New YorkHealth Hospitals, MetroPlus does not measure Return on Equity as a publicly heldcorporation would. However, when reserves are fully funded, MetroPlus estimatesnecessary retained earnings to continually invest into its operations to serve its members.Combined Non-Benefit Expenses: Non-benefit expenses are 46.47 PMPM, or 10% ofpremium.

MetroPlus Health Plan Inc.SERFF Number: MPHP- 133206955Page 4Final Premium RatesIn Exhibit 1, we calculate a required premium of 473.03 PMPM -- 426.56 PMPMfor Claims and 46.47 PMPM for Non-Benefit Expense. This is consistent with thecurrent composite premium rate of 473.03 PMPM, based on the Fund’s enrollmentdistribution by tier and current premium rates, which reflect the following underlyingtier factors:SingleIndividual SpouseIndividual Child(ren)Family1.002.151.532.75Exhibit 2 shows the final premium rates with no rate action.Riders: MetroPlus will offer an Age 29 rider, allowing policyholders to coverdependents through age 29. Exhibit 3 develops the Age 29 rider factor.Supporting Details for Material AssumptionsTrend: We trended claims from the midpoint of the experience period to themidpoint of rating period (10/1/2022-9/30/2023) using annual trends of 7.09% formedical and 8.85% for prescription drugs, based on industry trends from Buck’smost recent National Health Care Trend Survey, 42nd Edition (Attachment 2).We increased 2020 outpatient claim experience by an additional 2.4% to cover theenhancements MetroPlus made to the 2021 physician fee schedule.Mandates: We priced federal and state mandates as follows:1. NYS Infertility Mandate -- We increased the 2020 base period by 1%, consistentwith the prior rate filing. We assumed 2021 experience already reflects theadded cost of the mandate.2. Early Intervention Assessment – We projected an additional 3.6% increase inGME rates due to coverage of EI services, based on NYS Department of theBudget projections.3. Telehealth Payment Parity – MetroPlus’ Virtual Visit Program, which establishedtelehealth payment parity, was effective 1/31/2022 and is not expected to havea material financial impact not already reflected in the MetroPlus’ prior telehealthpayment rates.4. No Surprises Act – The surprise billing legislation established federal standardsto protect patients from balance billing for defined items and services provided

MetroPlus Health Plan Inc.SERFF Number: MPHP- 133206955Page 5by specified doctors, hospitals and air ambulance carriers on an out-of-networkbasis. It’s effective for plan or policy years beginning on or after Jan. 1, 2022, soit would first be effective for GoldCare on 10/1/2022. We assumed the impactwould be di minimus, as virtually all care is rendered in-network. Our trendassumption should be sufficient to provide for any additional cost of the Act.5. COVID testing – We project that any most additional OTC test kits will be orderedbefore the start of the 10/1/2022 rate period and that any additional costs in ratingperiod will be di minimus.Plan Change: During COVID, MetroPlus covered telehealth visits at 0 copay formembers; the experience period claims reflect this benefit. No other benefitschanged.COVID-19: We made no explicit COVID-19 adjustment, other than excluding Apriland May 2020 Medical (non-Drug) claims.New York State Department of Health Surcharges and Assessments: Exhibit 1reflects the added cost of the indigent care surcharge, based on the current 9.63%commercial rate promulgated by the New York State Department of Health. es/2009-04 thru 2023-12 payor rates.htm ).Weadjusted the rate by type of service to reflect the surcharge being applicable tofacility-provided services.Exhibit 1 also includes the projected cost of the Covered Lives Assessment forG r a d u a t e M e d i c a l E x p e n s e s ( GME). We calculated a composite 2021 /www.health.ny.gov/regulations/hcra/gme/2021 surcharges and assessments.htm )andtrended it to the rate period. As described above, we included an additional load formandated covered of Early Intervention services.Projected Loss RatioThe projected loss ratio is 90.2%.Out of Network benefitsMetroPlus is a PHSP and does not provide out-of-network benefits (other than in amedical emergency).Premium rate differencesRiders are available for coverage to Age 29. A 1.028% load is developed in Exhibit 3.

MetroPlus Health Plan Inc.SERFF Number: MPHP- 133206955Page 6Value-Based PaymentsMetroPlus has a value-based payment (VBP) arrangement with H H, at both thecorporate and network levels, covering certain lines of business, including GoldCare. TheVBP arrangement excludes care rendered to members who select primary carephysicians not at risk.The 2021 VBP risk percentage for 2021 is 86%. 2021 claims were less than 86%, andMetroPlus made a VBP of the difference to H H. (Had GoldCare claims exceeded 86%of GoldCare premium, H H would have been at risk for the shortfall.)MetroPlus and H H modify the VBP percentage, generally annually. In this filing, weassumed MetroPlus and H H will modify the percentage consistent with the 90.2%projected loss ratio.Other Supporting InformationSupporting the filing are the Rate Manual, New York State Department of FinancialServices Exhibits 1-7, and the HHS URRT. In completing NYS Exhibit 7: We included value-based payments; andWe summarized paid claims for each experience period based on claims incurred forthat period that were paid through 2/28/2022.Value-based payments are reflected in the capitation row of the URRT.Data sources/relianceOur analysis is based upon claim and enrollment data provided to us by MetroPlus.We relied upon MetroPlus for achievement of the administrative expense budget.We also relied upon MetroPlus for determination of which groups are considered largegroup.Attachments Exhibit 1 – Premium Rate DevelopmentExhibit 2 – GoldCare Monthly Premium Rates Under Additional Benefit OptionsExhibit 3 – Rider to Age 29 FactorAt

SERFF Tracking #: MPHP-133206955 State Tracking #: 2022050055 Company Tracking #: State: New York Filing Company: MetroPlus Health Plan TOI/Sub-TOI: HOrg02G Group Health Organizations - Health Maintenance (HMO)/HOrg02G.003C Large Group Only . state tracking number assigned and the effective date of coverage.): Yes 2022040166