Benefit Plan Factors Q3 2021 Last Updated: September 22, 2021 Effective Date: September 23, 2021 Pro: Professional; Instl: Institutional 1 of 37 Table of Contents A.2 Benefit Plan Factors for Capitation and Shared Risk Budgets ................................................................ 3 STANDARD HMO ................................................................................................................................... 3 SMALL GROUP HMO ........................................................................................................................... 18 COMMUNITY CARE HMO .................................................................................................................... 25 MEDICARE COB HMO ........................................................................................................................ 26 MEDICARE COB POS .......................................................................................................................... 27 STANDARD POS ................................................................................................................................... 28 SMALL GROUP POS ............................................................................................................................. 36 Effective Date: September 23, 2021 Pro: Professional; Instl: Institutional 2 of 37 A.2 Benefit Plan Factors for Capitation and Shared Risk Budgets Standard HMO Pro Instl Pro Instl Pro Instl Pro Instl Plan Factor Factor Plan Factor Factor Plan Factor Factor Plan Factor Factor 100 0.6755 0.7686 14U 1.0450 0.9035 17O 0.8912 0.9736 1I2 0.8370 0.8935 101 0.9679 0.9771 14V 1.0450 0.8771 17Q 0.9989 0.9805 1I3 0.8845 0.9389 104 0.9492 0.9733 14W 0.9965 0.9035 17R 0.9932 0.9805 1I5 0.8353 0.8843 106 0.9908 0.9903 14X 0.9965 0.8771 17S 0.9519 0.9937 1I9 0.7713 0.9337 109 1.0481 0.9776 14Y 0.9965 0.9035 17T 0.9488 0.9736 1IA 1.0059 0.9903 10F 0.9485 0.8984 14Z 0.9965 0.8771 17W 1.0066 0.9894 1KA 0.9973 0.9811 10J 0.8439 0.8794 150 0.9485 0.9035 184 0.9452 0.9354 1OA 1.0188 0.9834 10S 0.9483 0.9776 151 0.9485 0.8771 185 0.8876 0.9733 1Q7 0.8492 0.9555 10T 1.0517 0.9888 152 0.9015 0.9035 187 0.9932 0.9601 1Q8 0.8759 0.9317 10V 0.8532 0.9728 153 0.9015 0.8771 188 0.9932 0.9756 1Q9 0.8095 0.7528 10W 0.9497 0.9779 154 0.8821 0.9035 189 0.9380 0.9733 1R1 0.8396 0.6528 10Z 0.9552 0.9776 155 0.8821 0.8771 18W 0.9301 0.9314 1R2 0.8704 0.9280 112 0.9457 0.9782 156 0.8315 0.9035 18Y 0.9490 0.9438 1R4 0.9586 0.9604 115 0.9464 0.9624 157 0.8315 0.8771 18Z 0.9039 0.9748 1RA 1.0565 0.9765 117 0.8867 0.9056 158 0.8566 0.9030 192 0.9485 0.9776 1TF 0.8917 0.9018 11M 0.9017 0.9725 159 0.8566 0.8768 196 0.8250 0.8771 1TG 0.8917 0.8384 11R 0.8785 0.9084 15B 0.8129 0.9030 198 0.9418 0.9581 1TH 0.9418 0.9656 11S 0.9894 0.9811 15C 0.8129 0.8765 199 0.8129 0.9728 1TJ 0.8917 0.9650 11T 0.9325 0.9805 15D 1.0565 0.9817 19B 0.9576 0.9779 1TK 0.8437 0.9012 11X 0.9481 0.9699 15E 1.0761 0.9817 19C 0.8606 0.9779 1TL 0.8437 0.8378 11Y 0.9452 0.9733 15G 1.0037 0.9728 19D 0.8289 0.9199 1TM 0.7565 0.7100 12B 1.0543 0.9776 15N 0.9485 0.9776 19Q 0.8867 0.9056 1TP 0.8437 0.7243 12D 0.9452 0.9776 15P 0.9932 0.9776 19R 0.9015 0.9024 1TQ 0.8437 0.8315 12G 0.9457 0.9782 15Q 1.0512 0.9776 19S 0.8193 0.7895 1TR 0.7565 0.8306 12P 0.8998 0.9475 15R 0.9015 0.9394 19T 0.9965 0.9756 1TS 0.6755 0.8294 12R 0.9423 0.9371 15S 0.8671 0.9544 19V 0.8427 0.9596 1TT 0.7565 0.7697 12S 0.9485 0.9771 15T 0.9452 0.9776 19W 0.8081 0.9326 1TU 0.6755 0.7686 12U 0.9371 0.9693 15U 0.9932 0.9673 19X 0.8396 0.8022 1UN 0.8867 0.9056 12W 0.9146 0.9774 15V 0.9965 0.9035 19Y 0.9208 0.9888 1UP 0.8867 0.8401 12X 0.9590 0.9837 15W 0.9965 0.8771 1D1 0.8193 0.7927 1VZ 0.8917 0.9018 12Z 0.9710 0.9779 15X 0.9485 0.9035 1D7 0.8277 0.8122 1WB 0.8437 0.9644 131 0.9464 0.9308 15Y 0.9485 0.8771 1D8 0.9184 0.9662 1WC 0.8437 0.9012 132 0.9884 0.9897 15Z 0.9015 0.9033 1E2 0.8621 0.8846 1WD 0.8437 0.8378 133 0.9481 0.9587 160 0.9015 0.8771 1E3 0.7689 0.6942 1WF 0.6755 0.7088 134 0.8929 0.9463 161 0.8616 0.9033 1F3 0.8726 0.9027 1WG 0.8437 0.7243 135 0.9903 0.9400 162 0.8616 0.8771 1F4 0.7933 0.9168 1WH 0.8437 0.8315 138 0.8532 0.8817 164 0.9082 0.9774 1F5 0.9275 0.8872 1WJ 0.7565 0.8306 13K 1.1107 1.0222 165 1.0178 0.9794 1FA 1.0006 0.9765 1WK 0.6755 0.8294 140 0.9598 0.9742 16S 0.9965 0.9776 1G1 0.8226 0.9242 1WL 0.7565 0.7697 142 0.9101 0.9739 16T 0.8704 0.9544 1G3 0.8573 0.9027 1WM 0.6755 0.7686 143 0.9624 0.9452 16X 1.0450 0.9776 1G4 0.8527 0.9165 1WN 0.9418 0.9656 146 0.9543 0.9779 16Y 1.0512 0.9888 1G5 0.9485 0.9742 1WQ 0.8917 0.9650 147 0.9559 0.9779 17J 0.9485 0.9733 1G6 0.8315 0.9297 1XM 0.8628 0.8315 14L 0.9423 0.9722 17M 0.9526 0.9782 1G7 0.7770 0.8116 1XQ 0.7830 0.7697 14N 0.9385 0.9397 17N 0.9117 0.9776 1G8 0.9399 0.9354 1XS 0.9519 0.9656 Effective Date: September 23, 2021 Pro: Professional; Instl: Institutional 3 of 37 Pro Instl Pro Instl Pro Instl Pro Instl Plan Factor Factor Plan Factor Factor Plan Factor Factor Plan Factor Factor 1XV 0.9065 0.9018 26L 0.9588 0.9733 29R 0.9485 0.9024 2G5 0.9041 0.9412 1XW 0.9065 0.8384 26X 0.8867 0.9492 29S 0.9485 0.8760 2G6 0.9414 0.9409 1XX 0.9519 0.9656 26Y 0.7973 0.9015 29T 0.9015 0.9024 2GB 0.9385 0.9656 1XY 0.9519 0.9024 270 0.9015 0.9776 29U 0.9015 0.8760 2GE 0.9020 0.9730 1XZ 0.9065 0.9650 272 0.8790 0.7660 29V 0.8821 0.9024 2GF 0.9418 0.9397 1YB 0.8628 0.9644 274 0.9072 0.9354 29W 0.8821 0.8760 2H2 0.9017 0.9498 1YC 0.8628 0.9012 278 0.9211 0.9759 29X 0.8315 0.9024 2H5 0.9015 0.9380 1YD 0.8628 0.8378 27E 0.8384 0.6835 29Y 0.8315 0.8760 2H6 0.7995 0.9242 1YE 0.7830 0.7100 27F 0.7653 0.4687 29Z 0.8566 0.9021 2H7 0.9550 0.9509 1YF 0.7089 0.7088 27G 0.8542 0.6936 2BF 0.9065 0.8384 2H8 0.8836 0.9426 1YG 0.8628 0.7243 27H 0.9586 0.9377 2BG 0.9065 0.9018 2H9 0.7734 0.8843 1YH 0.8628 0.8315 27S 0.8427 0.8699 2BH 0.8628 0.9644 2I4 0.9211 0.9555 1YJ 0.7830 0.8306 27Y 0.9304 0.9547 2BJ 0.8628 0.9012 2I5 0.8124 0.9113 1YK 0.7089 0.8294 284 0.7990 0.9142 2BK 0.8628 0.8378 2I6 0.7804 0.8401 1YL 0.7830 0.7697 285 0.8922 0.9317 2BL 0.7830 0.7100 2I7 0.9254 0.9073 1YM 0.7087 0.7686 287 0.8969 0.9788 2BM 0.7089 0.7088 2I9 0.9031 0.9300 1ZF 0.8957 0.9056 288 0.9039 0.9277 2BN 0.8628 0.7243 2J1 0.9418 0.9656 1ZG 0.9089 0.9056 28D 0.9965 0.8372 2BP 0.8628 0.8315 2J2 0.9418 0.9024 1ZH 0.9089 0.8401 28E 0.9485 0.8372 2BQ 0.7830 0.8306 2J3 0.9418 0.8455 1ZJ 0.8957 0.8401 28F 0.9015 0.8372 2BR 0.7089 0.8294 2J4 0.9418 0.8389 205 0.9397 0.9774 28G 0.8616 0.8372 2BS 0.7830 0.7697 2J5 0.9418 0.7255 20E 0.8566 0.8852 28H 1.0450 0.8372 2BT 0.7087 0.7686 2J6 0.9418 0.8329 20G 0.8418 0.9521 28J 0.9965 0.8372 2BU 0.9519 0.9656 2J7 0.9418 0.7720 20H 0.9015 0.9596 28K 0.9485 0.8372 2BV 0.9519 0.9024 2J8 0.8917 0.9650 210 0.8917 0.8384 28L 0.9015 0.8372 2BW 0.9065 0.9650 2J9 0.8917 0.9018 211 0.8129 0.5767 28M 0.8821 0.8932 2C3 1.0512 0.9811 2JZ 0.8222 0.8027 212 0.8917 0.9018 28N 0.8315 0.8932 2C8 0.8296 0.9575 2K1 0.8917 0.8450 213 0.8437 0.9644 28P 0.8566 0.8369 2CQ 0.8437 0.9644 2K2 0.8917 0.8384 214 0.8437 0.9012 28Q 0.8129 0.8366 2CR 0.8998 0.9056 2K3 0.8917 0.6824 215 0.8437 0.8378 28V 0.9017 0.9349 2CW 0.7845 0.7775 2K4 0.8917 0.8320 216 0.7565 0.7100 28W 0.9681 0.9888 2CX 0.7845 0.8389 2K5 0.8917 0.7714 217 0.6755 0.7088 28X 0.9449 0.9360 2CY 0.7909 0.7775 2K6 0.8437 0.9644 219 0.8437 0.7243 28Y 0.8981 0.8926 2CZ 0.7909 0.8389 2K7 0.8437 0.9012 21C 0.8437 0.8315 28Z 0.9015 0.9774 2D3 0.9354 0.9745 2K8 0.8437 0.8444 21G 0.7565 0.8306 290 0.8998 0.9828 2D8 0.7851 0.8378 2K9 0.8437 0.8378 21J 0.6755 0.8294 291 0.9676 0.9776 2DD 0.9485 0.9035 2KB 0.8437 0.8378 21M 0.7565 0.7697 292 0.9908 0.9834 2DF 0.8566 0.9030 2KC 0.8437 0.6818 21N 0.6755 0.7686 296 0.9433 0.9782 2DQ 0.8129 0.9018 2KD 0.7565 0.8504 21Q 0.9418 0.9656 297 0.9953 0.9561 2DS 0.7708 0.8900 2KF 0.8917 0.9033 21R 0.9418 0.9024 298 0.9067 0.9774 2DT 0.8193 0.7892 2KG 0.7985 0.8510 21S 0.8917 0.9650 299 0.9433 0.9837 2ED 0.8129 0.9030 2KH 0.7247 0.8007 21T 0.8129 0.9728 29B 0.9970 0.9825 2EN 0.8129 0.8366 2KJ 0.5835 0.7898 21U 0.8019 0.8877 29C 0.9146 0.9774 2EP 0.8566 0.9021 2KL 0.8315 0.9027 21V 0.7935 0.8932 29D 0.8986 0.9716 2ER 0.9418 0.8329 2KN 0.7383 0.5744 21W 0.9485 0.9776 29E 0.8537 0.9374 2EY 0.8437 0.7709 2KP 0.9965 0.9776 24E 0.7078 0.7723 29G 0.9578 0.9745 2FF 0.8129 0.6950 2KR 0.8437 0.9021 24Q 0.8461 0.9337 29K 0.9973 0.9848 2FG 0.9015 0.9679 2KS 0.9418 0.9038 24T 0.8666 0.9308 29L 0.8986 0.9544 2FH 0.8704 0.9452 2KT 0.8437 0.8378 25N 0.8446 0.9297 29M 1.0481 0.9024 2FJ 0.8566 0.9679 2KU 0.7247 0.8007 268 0.8575 0.8765 29N 1.0512 0.8760 2FQ 0.9965 0.9756 2KV 0.8095 0.8108 26B 0.8167 0.9618 29P 0.9965 0.9024 2FS 0.9488 0.9779 2KW 0.9015 0.9776 26J 0.8437 0.8665 29Q 0.9965 0.8760 2FT 0.6898 0.7105 2KX 0.9418 0.8329 Effective Date: September 23, 2021 Pro: Professional; Instl: Institutional 4 of 37 Pro Instl Pro Instl Pro Instl Pro Instl Plan Factor Factor Plan Factor Factor Plan Factor Factor Plan Factor Factor 2KZ 0.8917 0.7714 2SZ 1.0018 0.9776 32K 0.8566 0.9679 37R 0.9576 0.9854 2L1 0.8437 0.6818 2T2 0.8449 0.9501 32L 0.8566 0.8340 37S 0.9015 0.9730 2L2 0.8437 0.8315 2T5 0.7995 0.8444 32M 0.8129 0.9676 37U 0.9452 0.9733 2L3 0.8437 0.7709 2TG 0.8628 0.8378 32N 0.8129 0.8338 37V 0.8981 0.9776 2LC 0.8437 0.8315 2TH 0.7515 0.8007 33K 0.8193 0.8036 39G 0.9528 0.9776 2LG 0.9015 0.9774 2TJ 0.8286 0.8108 33X 0.7997 0.7252 39L 0.8398 0.9722 2LJ 0.9965 0.9776 2TL 0.9519 0.8329 33Y 0.7995 0.8079 3A2 0.8566 0.9679 2LK 0.9485 0.9776 2TQ 0.8628 0.8315 33Z 0.8226 0.9242 3A6 0.9067 0.9429 2LL 1.0512 0.9776 2TR 0.7973 0.8900 342 0.9079 0.9685 3A7 0.9588 0.9716