Santa Clara Family Health Plan
Small Group Insurance Program
Expected Cost Analysis

August 7,2006

Executive Summary

The objective of this analysis was to determine the expected monthly cost of providing medical
coverage in currently uninsured individuals who work for small employers - defined as
employers with less than 50 employees who do not currently provide health insurance. The
insurance would only be available to the employee; dependent coverage would not be offered.

Buck also modeled the impact of the baseline claim costs running 5% lower and 5% higher than
projected. These variations provide additional information on the likely volatility of the actual
experience under the program.

While there are approximately 48,000 individuals that could be covered under the plan, based on
the survey conducted by the Santa Clara Family Health Plan, not all of the members would

participate. We used to results of the survey and the contribution rates that were developed in
our analysis to determine the expected participation rates. Based on the survey, we expect
approximately 65% of the eligible employees to enroll.

The expected cost of the program on a per enrolled participant basis increases as the participation
percentage decreases. As enrollment decreases, the underlying risk characteristics of the enrolled

population increases. This means that typically, the healthier portion of a population is the first
to elect not to participate, which increases the expected cost for the remaining population.
Because of this risk, we recommend that the initial premium rates be set assuming that only 60%
of the eligible employees enroll. This assumption will produce premium rates that provide
additional margin to cover adverse experience.

Table 1 shows the recommended premium rates and participant contributions by age band
assuming that the participant contributes 1/3 of the cost(and the remaining 2/3 is split between
the health plans and the employer).
Table 1

Small Group Insurance Program
Rates Effective January 1, 2007
Participant
Recommended Contribution

Premium

33.33%

40-64

$190.23
$204.60
$393.89

$63.41
$68.20
$131.30

Composite

$262.60

$87.53

Under 25
25-39

The table shows that the monthly contribution for the eligible employees ranges from $63.41 to

$131.30 assuming the 1/3 contribution for both employees and employers. If the health plans
elect to go with composite rates instead of age banded rates, the contributions are $87.53 for both
the employee and the employer.

The remainder of this report provides more detail on the methods and assumptions used to
develop the final cost estimates.

2

Development of Cost Estimates
This section describes the methodology used to develop the recommended premium rates, the
expected total cost, participant contributions, and net health plan costs for the new benefit plans
for eligible employees. This program is intended to provide coverage to eligible small group
employers and their employees who do not have coverage and have income of less than 300% of
the federal poverty level.

The first step was the development of the expected cost and utilization experience of the
expansion population. We used Medi-Cal experience for the four county area and our
proprietary cost and utilization databases to develop the expected cost patterns for this
population. Our proprietary model is built from Medi-Cal data for the State of California,
supplemented by Medicaid experience in other western U.S. states, OSHPD hospital data for the
State of California, and other employer based data sources for the Western U.S.
This model allows us to develop the expected per member per month(PMPM)claim costs for
the eligible population. Since this is primarily an uninsured or under-insured population, we
developed adjustment to reflect the estimated impact of pent-up demand. Exhibit VII provides
the detailed expected cost and utilization experience used in the analysis. The exhibit shows the
expected utilization rates per 1,000 covered members and the expected cost per service for each
detailed benefit category. W based the projections on the assumption that the fee schedule used
to pay providers would be consistent with Medicare reimbursement rates.

It then shows the impact of any per service copayment amount and the net expected cost on a
PMPM basis. The resulting claim costs were then loaded by 10% to account for the expected
administrative cost of the program. Table 2 below summarizes the general benefit provisions
that were used to develop the expected plan costs. This is based on the IHSS program offered in
San Mateo County and the VSP vision plan provided by Santa Clara Family Health Plan.
Table 2

Small Group Insurance Program
Category

Benefit

Hospitalization
Outpatient
Emergency
Maternity
Prescription
Drugs

Covered.

Covered. $5 co-payment
Covered. $25 co-payment - waived if admitted.
Covered.

Covered. Limited formulary. $5 co-payment. $25 co-payment for
name brands with generic equivalents. 30 day supply.

3

The second step was to develop the expected eligible and participating population for the
program. The Santa Clara Family Health Plan provided this data. Based on this data, there are
approximately 14,000 eligible employees who could be covered under this plan. In addition, the
survey provided information on the likelihood the eligible employers would offer coverage and
the likelihood that employees would enroll in coverage based on the required member premium
contribution. We were requested to develop participant contribution rates of 1/3 of the premium
rates for the eligible employees. An additional 1/3 would be paid by the employer and the health
plans would subsidize the remaining 1/3. In addition, we assumed that if the employee lost their
employment they could continue the coverage if they paid both the employer and employee
portion, or 2/3 of the cost.

Based on the data provided, we estimate that approximately 71% of the 14,000 employees would
participate. In addition, we assumed that 10% of the participating employees would lose
coverage and of those, 50% would elect to continue coverage. This means that in total about
75% of the eligible population would participate in the program. The total expected enrollment
under the composite rating method and under the age based rating method is shown in Exhibit IV
for the two groups of eligible employees.

The third step in the analysis was to develop the expected premium costs based on participation
level. Exhibit IV shows the expected premium costs for the two contribution scenarios. It then
shows the expected cost as the participation level falls. As enrollment decreases, the underlying
risk characteristics of the enrolled population increases. This means that typically, the healthier
portion of a population is the first to elect not to participate, which increases the expected cost on
a PMPM basis for the remaining population.
Since the expected participation rate for the employees is approximately 71% of the eligible
employees, we recommend that the health plan set the rates at the 60% participation rate level to
provide some additional conservatism in the initial rates for the plan.

Exhibit VI shows the monthly cost share for the eligible employees for the various participation
levels and the recommended 60% participation rates. It shows the contribution rates by age
range and on a composite basis for the two contribution rate scenarios. The contribution rates for
the higher participation scenarios will never apply because it is unlikely that a high percentage of
the eligible employees will enroll. To help control the risk and provide a higher likelihood that
the premium rates will cover the cost of the plan, we recommend that the 60% participation level
be used to develop the premiums and contributions for the plan.
The final step was to develop the expected total premium income, total plan cost, and net health
plan costs as well as the costs if the baseline claim costs run 5% lower and 5% higher than
projected for the two premium contribution scenarios. These variations provide the health plans
additional information on the likely volatility of the actual experience under the program.
Exhibit I-A through I-C provide the detailed results for the composite and age based rate options
separately for the first five years of the program. It combines the results for the employees who
are paying 1/3 of the cost and those who are paying 2/3 of the cost. Exhibit I-A provides the
expected results and Exhibits 1-B and I-C provides the results for the two sensitivity analysis
scenarios.

4

The exhibits first show the estimated number of eligible employees who will elect coverage. It
then shows the total premium rate collection, the total expected plan cost, the participant
contributions, the employer contribution, and the net health plan cost for each year. The
premium rates are based on the 60% participation level, while the costs are based on the
expected cost for each health plan individually. Since we expect almost 71% of the eligible
employees to enroll under this scenario, the underlying risk is improved and the cost is expected
to be less than the premium cost.

The exhibits show that using the 60% participation rate as the basis for developing the premium
rates protects the program if costs are equal to expected or are less than expected. If costs are
5% higher than expected then the program runs a deficit. The recommended premium rates will
provide protection if actual costs are up to 2.2% higher than expected.

Exhibits II-A through II-C provide the detailed results for the first five years of the program for
the employees who are contributing 33.3% of the premium cost(and the employer and health
plan evenly split the other 2/3 of the premium cost). Exhibit II-A provides the expected results
and Exhibits II-B and II-C provides the results for the two sensitivity analysis scenarios.
The exhibits first show the estimated number of eligible employees who will elect coverage for
each participating health plan. It then shows the total premium rate collection, the total expected
plan cost, the participant contributions, the employer contribution, and the net health plan cost
for each year. The premium rates are based on the 60% participation level, while the costs are
based on the expected cost for each contribution scenario. Since we expect almost 71% of the
eligible employees to enroll under this scenario, the underlying risk is slightly improved, so the
cost is expected to be less than the premium cost.
The exhibits show that using the 60% participation rate as the basis for developing the premium
rates protects the program if costs are equal to expected or are less than expected. If costs are
5% higher than expected then the program runs a deficit. The recommended premium rates will
provide protection if actual costs are up to 2.5% higher than expected.
Exhibits III-A through III-C provide the detailed results for the first five years of the program for
the employees who are contributing 66.7% of the premium cost. Exhibit III-A provides the
expected results and Exhibits III-B and III-C provides the results for the two sensitivity analysis
scenarios.

The exhibits first show the estimated number of eligible employees who will elect coverage for
each participating health plan. It then shows the total premium rate collection, the total expected
plan cost, the participant contributions, the employer contribution, and the net health plan cost
for each year. The premium rates are based on the 60% participation level, while the costs are
based on the expected cost for each contribution scenario. These individuals are likely to be
higher risk, so the exhibit shows that the premiums are not likely to cover the expected costs
under any of the three sensitivity scenarios.

5

The exhibits show that these individuals will create a loss of approximately 5.5% to 6.5% of the
premium rates depending on whether the age based or composite rates are used. If their
experience is 5% better than expected these losses fall to 0.2% to 1.2%. If costs are 5% higher
than expected then the deficit increases to 10.8% to 11.8%. The expected high utilization of this
population is one of the key reasons to set the premium rates conservatively yet not so
conservative as to discourage enrollment in the program.
For Exhibit I, Exhibit II, and Exhibit III the premium rates, plan costs, and participant
contributions are assumed to increase 8% per year.

6

Exhibit I-A

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost Equals Expected Cost

Combined33.3% and 66.67% Employee Contribution
Age Based
Under 25
25-39
40-64
Composite
Number of Participants
Workers

Total

35,805

12,948

14,390

8,656

35,994

Year 1

$112,828,716

$29,557,176

$105,801,647

$121,855,872
$131,604,858
$142,135,825
$153,504,629

$31,921,999
$34,476,381
$37,232,751
$40,211,309

$35,330,328
$38,155,373

$40,914,143

Year 2

$44,186,111

$41,208,355
$44,504,816
$48,065,478

$47,720,875
$51,539,209
$55,661,888

$114,263,483
$123,405,611
$133,276,776
$143,938,675

$110,476,666
$119,320,812

$29,002,551
$31,323,149
$33,828,204

$34,677,664

$37,452,026

$39,967,472
$43,164,632

$40,447,153

$46,617,625

$103,647,687
$111,939,807
$120,892,982

$36,534,900
$39,457,221

$43,683,669
$47,179,038

$50,347,276

$130,565,845

$54,375,426

$141,011,685

$10,440,583

$12,441,317

$11,275,369

$14,204,528

$13,435,527
$14,511,829
$15,672,046
$16,925,299

$13,975,572
$15,093,192
$16,300,222
$17,604,112
$19,012,312

$36,857,472
$39,804,088
$42,989,713
$46,428,560
$50,142,139

$9,264,201
$10,004,928
$10,805,556
$11,670,468
$12,604,047

$11,112,235
$12,000,236
$12,961,559
$13,997,832
$15,117,202

$13,301,215
$14,364,907
$15,513,695
$16,754,669
$18,094,920

$33,677,651
$36,370,071
$39,280,810
$42,422,969
$45,816,169

Total Premium Rates

Year 3
Year 4
Year 5

Total Plan Cost
Year 1
Year 2
Year 3
Year 4

$128,864,092
$139,170,569

Year 5

$150,304,887

Employee Contributions
Year 1
$39,296,068
Year 2
$42,443,166
Year 3
$45,837,183
Year 4
$49,505,055
Year 5
$53,464,741

$12,177,662
$13,152,402

Employer Contribution
Year 1

Year 2
Year 3
Year 4

Year 5

$35,920,211
$38,796,947
$41,899,390
$45,252,162
$48,871,678

Exhibit I-A

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost Equals Expected Cost
Combined 33.3% and 66.67%) Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Health Plan Contribution
Year 1
Year 2

Year 3
Year 4
Year 5

$35,260,387
$38,080,699
$41,127,519
$44,413,352
$47,968,468

Est Gain/(Loss) to Health Plan
Year 1
$2,352,050
Year 2
$2,535,060
Year 3
$2,740,766
Year 4
$2,965,256
Year 5
$3,199,742

$9,297,767
$10,042,852
$10,844,986
$11,712,030
$12,648,646

$554,625

$652,664

$598,850
$648,177

$703,347
$761,202

$697,851
$754,088

$821,147
$886,440

$11,124,112

$12,690,685

$12,016,263

$13,706,533

$12,973,765
$14,013,791
$15,136,537

$14,803,708

$15,988,495
$17,268,194

$33,112,564
$35,765,648
$38,622,459
$41,714,316
$45,053,377

$946,671
$1,021,479

$2,153,960

$1,103,250

$2,512,629

$1,191,933

$2,710,931
$2,926,990

$1,286,462

$2,323,676

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected

Exhibit I-B

Combined 33.3% and 66.67% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Number of Participants
Workers

35,805

12,948

14,390

8,656

35,994

$112,828,716
$121,855,872
$131,604,858
$142,135,825
$153,504,629

$29,557,176
$31,921,999
$34,476,381
$37,232,751
$40,211,309

$35,330,328
$38,155,373
$41,208,355
$44,504,816
$48,065,478

$40,914,143
$44,186,111
$47,720,875
$51,539,209
$55,661,888

$105,801,647
$114,263,483
$123,405,611
$133,276,776
$143,938,675

$104,952,833
$113,354,771
$122,420,887
$132,212,041
$142,789,642

$27,552,423
$29,756,992

$32,943,781
$35,579,425
$38,424,795
$41,499,485
$44,820,087

$37,969,098
$41,006,401
$44,286,744
$47,829,912
$51,656,655

$98,465,302

$12,441,317

$13,975,572
$15,093,192
$16,300,222

Total Premium Rates
Year 1

Year 2
Year 3
Year 4

Year 5

Total Plan Cost
Year 1
Year 2

Year 3
Year 4
Year 5

Employee Contributions
Year 1
$39,296,068
Year 2
$42,443,166
Year 3
$45,837,183
Year 4
$49,505,055
Year 5
$53,464,741

$32,136,794
$34,708,155
$37,484,360

$10,440,583
$11,275,369

$12,177,662
$13,152,402
$14,204,528

$13,435,527
$14,511,829
$15,672,046
$16,925,299

$17,604,112
$19,012,312

$9,264,201
$10,004,928
$10,805,556
$11,670,468
$12,604,047

$11,112,235
$12,000,236
$12,961,559
$13,997,832
$15,117,202

$13,301,215
$14,364,907
$15,513,695
$16,754,669
$18,094,920

$106,342,818
$114,848,333
$124,037,552
$133,961,102

$36,857,472
$39,804,088

$42,989,713
$46,428,560
$50,142,139

Employer Contribution
Year 1

Year 2

Year 3
Year 4
Year 5

$35,920,211
$38,796,947
$41,899,390
$45,252,162
$48,871,678

$33,677,651

$36,370,071
$39,280,810
$42,422,969
$45,816,169

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected

Exhibit I-B

Combined 33.3% and 66.67% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Health Plan Contribution
Year 1
Year 2

Year 3
Year 4

Year 5

$29,736,554
$32,114,658
$34,684,314
$37,454,824
$40,453,223

Est Gain/(Loss) to Health Plan
Year 1
$7,875,883
Year 2
$8,501,101
Year 3
$9,183,971
Year 4
$9,923,784
Year 5
$10,714,987

$7,847,639
$8,476,695
$9,153,576
$9,885,285
$10,675,785

$9,390,229
$10,143,662
$10,951,407
$11,829,607
$12,777,586

$10,692,311
$11,548,302
$12,472,827
$13,471,131
$14,549,423

$32,577,810
$35,186,023
$38,002,794

$2,004,753

$2,386,547
$2,575,948
$2,783,560
$3,005,331
$3,245,391

$2,945,045
$3,179,710
$3,434,131
$3,709,297
$4,005,233

$7,336,345
$7,920,665
$8,557,278
$9,239,224
$9,977,573

$2,165,007
$2,339,587
$2,524,596
$2,726,949

$27,930,179
$30,168,659

Exhibit I-C

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected

Combined 33.3% and 66.67% Employee Contribution
Age Based
Under 25
25-39
40-64
Composite
Number of Participants
Workers

Total

35,805

12,948

14,390

8,656

35,994

$112,828,716
$121,855,872
$131,604,858
$142,135,825
$153,504,629

$29,557,176
$31,921,999

$40,211,309

$35,330,328
$38,155,373
$41,208,355
$44,504,816
$48,065,478

$40,914,143
$44,186,111
$47,720,875
$51,539,209
$55,661,888

$105,801,647
$114,263,483
$123,405,611
$133,276,776
$143,938,675

$116,000,499
$125,286,853
$135,307,297
$146,129,097
$157,820,132

$30,452,679
$32,889,306
$35,519,614
$38,361,645
$41,430,082

$36,411,547

$39,324,627
$42,469,511
$45,867,853
$49,537,990

$41,965,846
$45,322,863
$48,948,506
$52,864,640
$57,094,197

$108,830,072
$117,536,796
$126,937,631
$137,094,138
$148,062,269

$10,440,583
$11,275,369

$12,441,317

$13,975,572

$36,857,472

$13,435,527

$15,093,192

$39,804,088

$12,177,662

$14,511,829

$16,300,222

$42,989,713

$13,152,402

$15,672,046
$16,925,299

$17,604,112
$19,012,312

$46,428,560

$11,112,235
$12,000,236

$13,301,215

$33,677,651

$14,364,907
$15,513,695

$36,370,071
$39,280,810

$16,754,669
$18,094,920

$42,422,969
$45,816,169

Total Premium Rates
Year 1
Year 2

Year 3
Year 4
Year 5

$34,476,381
$37,232,751

Total Plan Cost
Year 1

Year 2
Year 3
Year 4
Year 5

Employee Contributions
Year 1
$39,296,068
Year 2
$42,443,166
Year 3
$45,837,183
Year 4
$49,505,055
Year 5
$53,464,741

$14,204,528

$50,142,139

Employer Contribution
Year 1
Year 2
Year 3
Year 4

Year 5

$35,920,211
$38,796,947
$41,899,390
$45,252,162
$48,871,678

$9,264,201
$10,004,928
$10,805,556
$11,670,468
$12,604,047

$12,961,559
$13,997,832
$15,117,202

Exhibit I-C

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected
Combined33,3% and 66.67% Employee Contribution
Age Based
Under 25
25-39
40-64
Composite

Total

Health Plan Contribution
Year 1

$40,784,220

$10,747,895

$12,857,995

Year 2

$44,046,740

$11,609,009

$13,888,864

Year 3

$47,570,724

$12,536,396

Year 4

$51,371,880
$55,483,713

Year 5

$13,538,775
$14,621,507

$14,996,123
$16,197,975
$17,495,489

$14,689,059
$15,864,764
$17,134,589
$18,505,859
$19,986,965

$48,242,609
$52,103,961

($895,503)
($967,307)
($1,043,233)
($1,128,894)
($1,218,773)

($1,081,219)
($1,169,254)
($1,261,156)
($1,363,037)
($1,472,512)

($1,051,703)
($1,136,752)
($1,227,631)
($1,325,431)
($1,432,309)

($3,028,425)
($3,273,313)
($3,532,020)
($3,817,362)
($4,123,594)

$38,294,949
$41,362,637
$44,667,108

Est Gain/(Loss) to Health Plan
Year 1
Year 2
Year 3
Year 4
Year 5

($3,171,783)
($3,430,981)
($3,702,439)
($3,993,272)
($4,315,503)

Exhibit II-A

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost Equals Expected Cost

33.3% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Number of Participants
Workers

34,198

12,175

13,578

8,442

34,195

$107,764,738
$116,386,737
$125,698,169
$135,756,485
$146,615,034

$27,792,603

$33,336,706

$30,016,245

$36,002,339

$32,418,129
$35,009,943
$37,810,680

$38,883,047
$41,993,495
$45,353,236

$39,902,633
$43,093,709
$46,541,084
$50,265,019
$54,285,774

$101,031,942
$109,112,293
$117,842,260
$127,268,457
$137,449,690

$27,114,699

$32,523,655
$35,125,743
$37,934,760
$40,970,257
$44,248,530

$38,929,101
$42,043,186
$45,406,479
$49,039,240
$52,962,744

$98,567,455

$11,112,235

$13,301,215
$14,364,907
$15,513,695
$16,754,669
$18,094,920

Total Premium Rates
Year 1
Year 2
Year 3
Year 4

Year 5

Total Plan Cost
Year 1
Year 2
Year 3
Year 4
Year 5

$105,134,227
$113,551,039
$122,632,660
$132,440,646
$143,036,555

Employee Contributions
Year 1
$35,920,211
Year 2
$38,796,947
Year 3
$41,899,390
Year 4
$45,252,162
Year 5
$48,871,678

$29,284,284
$31,626,267
$34,156,719
$36,888,789

$9,264,201
$10,004,928
$10,805,556

$12,000,236

$12,604,047

$12,961,559
$13,997,832
$15,117,202

$11,670,468

$106,453,213
$114,967,506
$124,166,216

$134,100,063

$33,677,651

$36,370,071
$39,280,810
$42,422,969
$45,816,169

Employer Contribution
Year 1

$35,920,211

$9,264,201

$11,112,235

Year 2

$10,004,928

Year 4

$38,796,947
$41,899,390
$45,252,162

$11,670,468

Year 5

$48,871,678

$12,604,047

$12,000,236
$12,961,559
$13,997,832
$15,117,202

Year 3

$10,805,556

$13,301,215
$14,364,907
$15,513,695
$16,754,669
$18,094,920

$33,677,651

$36,370,071
$39,280,810
$42,422,969
$45,816,169

Exhibit II-A

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost Equals Expected Cost
33.3% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Health Plan Contribution
Year 1
Year 2

Year 3
Year 4

Year 5

$33,293,805
$35,957,145
$38,833,880
$41,936,322
$45,293,199

Est Gain/(Loss) to Health Plan
Year 1
$2,630,511
Year 2
$2,835,698
Year 3
$3,065,509
Year 4
$3,315,839
Year 5
$3,578,479

$8,586,297

$10,299,185

$12,326,671

$31,212,153

$9,274,428

$11,125,271

$13,313,372

$10,015,155
$10,815,783
$11,680,695

$12,011,642
$12,974,593
$14,014,126

$14,379,089
$15,529,902
$16,772,904

$33,713,071
$36,405,886
$39,320,278
$42,467,725

$677,904

$813,051

$973,532

$731,961

$876,596
$948,287
$1,023,238
$1,104,706

$1,050,523

$791,862
$853,224

$921,891

$1,134,605
$1,225,779

$1,323,030

$2,464,487
$2,659,080
$2,874,754
$3,102,241
$3,349,627

Exhibit II-B

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected

J3.J% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Number of Participants
Workers

34,198

12,175

13,578

8,442

34,195

Year 1

$107,764,738

$27,792,603

$116,386,737

$30,016,245

$33,336,706
$36,002,339

$39,902,633

Year 2

$43,093,709

$101,031,942
$109,112,293

Year 3

$125,698,169
$135,756,485
$146,615,034

$32,418,129

$38,883,047

$46,541,084

$117,842,260

$35,009,943

$41,993,495
$45,353,236

$50,265,019

$127,268,457

$54,285,774

$137,449,690

$32,523,655

$38,929,101

$35,125,743

$42,043,186
$45,406,479

$98,567,455
$106,453,213
$114,967,506

Total Premium Rates

Year 4

Year 5

$37,810,680

Total Plan Cost
Year 1

$105,134,227

Year 2

$113,551,039

$27,114,699
$29,284,284

Year 3

$122,632,660

$31,626,267

Year 4

$132,440,646

$34,156,719

Year 5

$143,036,555

$36,888,789

$37,934,760
$40,970,257
$44,248,530

$49,039,240

$52,962,744

$124,166,216
$134,100,063

$11,112,235

$13,301,215

$33,677,651

$12,000,236

$14,364,907

$36,370,071
$39,280,810
$42,422,969
$45,816,169

Employee Contributions
Year 1

$35,920,211

Year 2

$38,796,947

$9,264,201
$10,004,928

Year 3

$41,899,390
$45,252,162

$10,805,556
$11,670,468

$12,961,559

$15,513,695

Year 4

$13,997,832

$16,754,669

Year 5

$48,871,678

$12,604,047

$15,117,202

$18,094,920

$13,301,215
$14,364,907
$15,513,695
$16,754,669
$18,094,920

Employer Contribution
Year 1

$35,920,211

$9,264,201

$11,112,235

Year 2

$38,796,947

$10,004,928

$12,000,236

Year 3

$41,899,390

$12,961,559

Year 4

$45,252,162
$48,871,678

$10,805,556
$11,670,468
$12,604,047

Year 5

$13,997,832
$15,117,202

$33,677,651
$36,370,071
$39,280,810
$42,422,969
$45,816,169

Exhibit II-B

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected
33.3% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Health Plan Contribution
Year 1

$28,037,094
$30,279,593
$32,702,247
$35,314,290
$38,141,371

Est Gain/(Loss) to Health Plan
Year 1
$7,887,222
Year 2
$8,513,250
Year 3
$9,197,142
Year 4
$9,937,871
Year 5
$10,730,307

Year 2
Year 3
Year 4
Year 5

$7,230,562

$8,673,002

$7,810,214
$9,107,947
$9,836,256

$9,368,984
$10,114,904
$10,926,080
$11,801,700

$2,033,639
$2,196,175
$2,373,175
$2,561,060
$2,766,330

$2,439,234
$2,632,883
$2,845,025
$3,071,751
$3,317,132

$8,433,842

$10,380,216
$11,211,213
$12,108,765
$13,077,940
$14,124,767

$26,283,780
$28,390,411
$30,657,511
$33,111,967
$35,762,723

$2,919,987

$7,392,860

$3,152,682
$3,404,929
$3,677,741
$3,971,167

$7,981,740
$8,623,129
$9,310,552
$10,054,629

Exhibit 11-C

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected
33.3% Employee Contribution
Age Based
Composite
Number of Participants
Workers

Under 25

25-39

40-64

Total

34,198

12,175

13,578

8,442

34,195

$107,764,738
$1 16,386,737
$125,698,169
$135,756,485
$146,615,034

$27,792,603

$33,336,706
$36,002,339

$39,902,633
$43,093,709

$101,031,942

$38,883,047

$117,842,260
$127,268,457

$37,810,680

$41,993,495
$45,353,236

$46,541,084
$50,265,019

$54,285,774

$137,449,690

$27,114,699

$32,523,655

$38,929,101

$98,567,455

$29,284,284

$35,125,743

$42,043,186

$106,453,213
$114,967,506

Total Premium Rates
Year 1
Year 2
Year 3
Year 4

Year 5

$30,016,245
$32,418,129
$35,009,943

$109,112,293

Total Plan Cost
Year 1

Year 2
Year 3
Year 4

Year 5

$105,134,227
$113,551,039
$122,632,660
$132,440,646
$143,036,555

Employee Contributions
Year 1
$35,920,211
Year 2
$38,796,947
Year 3
$41,899,390
Year 4
$45,252,162
Year 5
$48,871,678

$31,626,267

$37,934,760

$34,156,719

$40,970,257

$36,888,789

$44,248,530

$45,406,479
$49,039,240
$52,962,744

$9,264,201

$11,112,235

$13,301,215

$33,677,651

$10,004,928

$14,364,907
$15,513,695

$36,370,071
$39,280,810

$16,754,669

$42,422,969

$12,604,047

$12,000,236
$12,961,559
$13,997,832
$15,117,202

$18,094,920

$45,816,169

$33,677,651
$36,370,071

$10,805,556
$11,670,468

$124,166,216
$134,100,063

Employer Contribution
Year 1

$35,920,211

$9,264,201

$11,112,235

$13,301,215

Year 2

$38,796,947
$41,899,390
$45,252,162
$48,871,678

$10,004,928

$12,000,236

$14,364,907

$10,805,556

$12,961,559
$13,997,832
$15,117,202

$15,513,695
$16,754,669
$18,094,920

Year 3
Year 4
Year 5

$11,670,468
$12,604,047

$39,280,810
$42,422,969
$45,816,169

Exhibit II-C

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected
33,3% Employee Contribution
Age Based

Composite

Under 25

25-39

40-64

Total

Health Plan Contribution
Year 1
Year 2
Year 3
Year 4

Year 5

$38,550,516
$41,634,697
$44,965,513
$48,558,354
$52,445,027

$9,942,032

$12,523,619
$13,525,134

$11,925,368
$12,881,558
$13,908,380
$15,023,106
$16,226,553

$14,273,126
$15,415,531
$16,649,413
$17,981,864
$19,421,041

$45,528,589
$49,172,728

($677,831)
($732,253)
($789,451)
($854,612)
($922,548)

($813,132)
($879,691)
($948,451)
($1,025,275)
($1,107,721)

($972,923)
($1,051,636)
($1,135,719)
($1,226,183)
($1,325,107)

($2,463,886)
($2,663,580)
($2,873,621)
($3,106,070)
($3,355,376)

$10,738,642
$11,596,468

$36,140,526
$39,035,731
$42,154,261

Est Gain/(Loss) to Health Plan
Year 1
Year 2
Year 3
Year 4
Year 5

($2,626,200)
($2,841,854)
($3,066,124)
($3,306,193)
($3,573,349)

Exhibit III-A

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost Equals Expected Cost
66.67% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Number of Participants
Workers

1,607

773

812

214

1,799

$5,063,978
$5,469,135

$1,764,573

$1,993,622

$1,011,510

$4,769,705

$1,905,754

Year 4

$5,906,689
$6,379,340

$2,058,252
$2,222,808

$2,153,034
$2,325,308
$2,511,321

$1,092,402
$1,179,791
$1,274,190

$5,151,190
$5,563,351
$6,008,319

Year 5

$6,889,595

$2,400,629

$2,712,242

$1,376,114

$6,488,985

$5,342,439
$5,769,773

$1,887,852

$2,154,009
$2,326,283

$1,038,371
$1,121,446
$1,211,146
$1,308,036
$1,412,682

$5,080,232

Total Premium Rates
Year 1
Year 2
Year 3

Total Plan Cost
Year 1
Year 2
Year 3

$2,038,865

Year 4

$6,231,432
$6,729,923

Year 5

$7,268,332

$2,378,181
$2,568,432

Year 2

$3,375,857
$3,646,219

$1,176,382
$1,270,441

Year 3

$3,937,793

Year 4

$4,252,893

$1,372,106
$1,481,934

Year 5

$4,593,063

$1,600,481

Year 1

$0

Year 2

$2,201,937

$2,512,393
$2,713,412
$2,930,508

$5,486,594
$5,925,476
$6,399,629
$6,911,622

Employee Contributions
Year 1

$1,329,082
$1,435,291
$1,550,270

$674,357

$3,179,821
$3,434,017

$1,808,097

$728,285
$786,527
$849,443
$917,392

$4,325,970

$0

$0

$0

$0

$0

$0

$0

$0

$0

Year 3

$0

$0

$0

$0

$0

Year 4

$0

$0

$0

$0

$0

Year 5

$0

$0

$0

$0

$0

$1,674,214

$3,708,903
$4,005,591

Employer Contribution

Exhibit III-A

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost Equals Expected Cost
66.67% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Health Plan Contribution
Year 1

$1,966,582

$711,470

$824,927

$364,014

$1,900,411

Year 2

$2,123,554
$2,477,030

$896,247

Year 5

$2,675,269

$967,951

$424,619
$458,593
$495,290

$2,216,573

Year 4

$890,992
$962,123
$1,039,198
$1,122,411

$2,052,577

$2,293,639

$768,424
$829,831

$393,161

Year 3

$2,585,652

Est Gain/(Loss) to Health Plan
Year 1
($278,461)
Year 2
($300,638)
Year 3
($324,743)
Year 4
($350,583)
Year 5
($378,737)

($123,279)
($133,111)
($143,685)
($155,373)
($167,803)

($160,387)
($173,249)
($187,085)
($202,091)
($218,266)

($26,861)
($29,044)
($31,355)
($33,846)
($36,568)

($310,527)
($335,404)
($362,125)
($391,310)
($422,637)

$2,394,038

Exhibit Ill-B

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected
66.67% Employee Contribution
Age Based
Composite
Number of Participants
Workers

Under 25

25-39

40-64

Total

1,607

773

812

214

1,799

Year 1

$5,063,978

$1,764,573

Year 2

$5,469,135

$1,905,754

$1,993,622
$2,153,034

$1,011,510
$1,092,402

$4,769,705
$5,151,190

Year 3

$5,906,689

Year 4

$6,379,340

$2,325,308
$2,511,321

$1,179,791
$1,274,190

$5,563,351
$6,008,319

Year 5

$6,889,595

$2,058,252
$2,222,808
$2,400,629

$2,712,242

$1,376,114

$6,488,985

Year 1

$5,342,439

$1,887,852

$1,038,371

$5,080,232

Year 2

$5,769,773
$6,231,432
$6,729,923
$7,268,332

$2,038,865
$2,201,937

$1,121,446

$5,486,594
$5,925,476

Year 1
Year 2

Total Premium Rates

Total Plan Cost

$2,378,181
$2,568,432

$2,154,009
$2,326,283
$2,512,393
$2,713,412
$2,930,508

$1,412,682

$6,911,622

$3,375,857

$1,176,382

$1,329,082

$674,357

$3,179,821

$3,646,219
$3,937,793

$1,270,441

$1,435,291

$728,285

Year 3

$1,372,106

$1,550,270

$786,527

$3,434,017
$3,708,903

Year 4

$4,252,893

$1,481,934

$1,674,214

$849,443

$4,005,591

Year 5

$4,593,063

$1,600,481

$1,808,097

$917,392

$4,325,970

Year 1

$0

$0

$0

$0

$0

Year 2

$0

$0

$0

$0

$0

Year 3

$0

$0

$0

$0

$0

Year 4

$0

$0

$0

$0

$0

Year 5

$0

$0

$0

$0

$0

Year 3
Year 4

Year 5

$1,211,146
$1,308,036

$6,399,629

Employee Contributions

Employer Contribution

Exhibit III-B

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected

66.67% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Health Plan Contribution
Year 1

$1,699,460
$1,835,065
$1,982,067
$2,140,534
$2,311,852

Est Gain/(Loss) to Health Plan
Year 1
($11,339)
Year 2
($12,149)
Year 3
($13,171)
Year 4
($14,087)
Year 5
($15,320)

Year 2

Year 3
Year 4
Year 5

$617,077

$717,227

$312,095

$1,646,399

$666,481

$774,678

$719,734
$777,338
$839,529

$836,503
$903,527
$975,886

$337,089
$364,062
$393,191
$424,656

$1,778,248
$1,920,299
$2,074,056
$2,240,071

($28,886)
($31,168)
($33,588)
($36,464)
($39,381)

($52,687)
($56,935)
($61,465)
($66,420)
($71,741)

$25,058
$27,028

($56,515)
($61,075)
($65,851)
($71,328)
($77,056)

$29,202

$31,556
$34,066

Exhibit III-C

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected
66.67% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Number of Participants
Workers

1,607

773

812

214

1,799

$5,063,978
$5,469,135

$1,764,573
$1,905,754

Year 4

$5,906,689
$6,379,340

$2,058,252
$2,222,808

$1,011,510
$1,092,402
$1,179,791
$1,274,190

$4,769,705
$5,151,190
$5,563,351
$6,008,319

Year 5

$6,889,595

$2,400,629

$1,993,622
$2,153,034
$2,325,308
$2,511,321
$2,712,242

$1,376,114

$6,488,985

Year 1

$5,342,439

$1,887,852

$1,038,371

Year 2

$2,038,865
$2,201,937

$5,080,232
$5,486,594

Year 4

$5,769,773
$6,231,432
$6,729,923

Year 5

$7,268,332

Total Premium Rates
Year 1
Year 2

Year 3

Total Plan Cost

Year 3

$2,378,181
$2,568,432

$2,154,009
$2,326,283
$2,512,393
$2,713,412
$2,930,508

$1,329,082
$1,435,291
$1,550,270
$1,674,214
$1,808,097

$917,392

$3,179,821
$3,434,017
$3,708,903
$4,005,591
$4,325,970

$1,121,446
$1,211,146
$1,308,036
$1,412,682

$5,925,476
$6,399,629
$6,911,622

Employee Contributions
Year 1

$3,375,857

Year 2

$3,646,219

Year 3

$3,937,793

Year 4

$4,252,893

Year 5

$4,593,063

$1,176,382
$1,270,441
$1,372,106
$1,481,934
$1,600,481

Year 1

$0

$0

$0

$0

$0

Year 2

$0

$0

$0

$0

$0

Year 3

$0

$0

$0

$0

$0

Year 4

$0

$0

$0

$0

$0

Year 5

$0

$0

$0

$0

$0

$674,357
$728,285

$786,527
$849,443

Employer Contribution

Exhibit IIl-C

Santa Clara Family Health Plan
Small Group Insurance Program
Cost Using Developed Premium Rates
Actual Cost 5% Lower than Expected
66.67% Employee Contribution
Age Based
Composite

Under 25

25-39

40-64

Total

Health Plan Contribution
Year 1

$805,863

$932,627

$415,933

$2,154,423

Year 2

$2,233,704
$2,412,043

$870,367

$1,007,306

$449,233

Year 3

$2,605,211

$939,928

$1,087,743

$485,176

$2,326,906
$2,512,847

Year 4

:
$2,813,526
:
$3,038,686

$1,015,156

$523,995

$1,096,373

$1,174,869
$1,268,936

$565,924

$2,714,020
$2,931,233

($217,672)
($235,054)
($253,782)
($274,282)
($296,225)

($268,087)
($289,563)
($312,705)
($337,762)
($364,791)

($78,780)
($85,116)
($91,912)
($99,248)
($107,202)

($564,539)
($609,733)
($658,399)
($711,292)
($768,218)

Year 5

Est Gain/(Loss) to Health Plan
Year 1
Year 2
Year 3

Year 4
Year 5

($545,583)
($589,127)
($636,315)
($687,079)
($742,154)

Exhibit IV

Santa Clara Family Health Plan
Small Group Insurance Program

Census Assumptions Used in Analysis

PARTICIPATION ASSUMPTIONS

Composite

Under 25

25-39

40-64

Total

Total Eligible

48,000

15,000

17,000

16,000

48,000

33.3% Contribution

34,198

12,175

13,578

8,442

34,195

66.7% Contribution

1,607

773

812

214

1,799

35,805

12,948

14,390

8,656

35,994

Total Participating

Exhibit V

Santa Clara Family Health Plan

Small Group Insurance Program
Participation Based Premiums Per Month

Recom’d

Participation Level
100%

90%

80%

70%

60%

50%

40%

Rates

Premium Rate

Composite

$229.12 $235.99 $242.87 $257.68 $268.97 $274.53 $287.11

$262.60

Under 25

$175.58 $180.85 $186.11 $197.46 $206.11 $210.38 $220.02

$190.23

25-39

$188.31

$193.96 $199.61 $211.78 $221.06 $225.63 $235.97

$204.60

40-64

$322.68 $332.36 $342.04 $362.90 $378.80 $386.63 $404.35

$393.89

Exhibit VI

Santa Clara Family Health Plan

Small Group Insurance Program

Monthly Contributions at Various Participation Levels
Recom'd

Participation Level
Cont % Category

100%

90%

80%

70%

60%

50%

40%

Rates

33.3% Contribution
Under 25

$58.53

$60.28

$62.04

$65.82

$68.70

$70.13

$73.34

$63.41

25-39

$62.77

$64.65

$66.54

$70.59

$73.69

$75.21

$78.66

$68.20

$120.97 $126.27 $128.88 $134.78

$131.30

40-64

Composite

$107.56 $110.79 $114.01

$76.37

$78.66

$80.96

$85.89

$89.66

$91.51

$95.70

$87.53

Under 25

$1 17.06 $120.56 $124.08 $131.64 $137.40 $140.26 $146.68

$126.82

25-39

$125.54 $129.30 $133.08 $141.18 $147.38 $150.42 $157.32

$136.40

40-64

$215.12 $221.58 $228.02 $241.94 $252.54 $257.76 $269.56

$262.60

Composite

$152.74 $157.32 $161.92 $171.78 $179.32 $183.02 $191.40

$175.06

66.7% Contribution

Exhibit VII

Santa Clara Family Health Plan
Small Group Insurance Program
Base Cost Assumptions

Frequency
per 1000
Members

Average

Per Capita
Monthly

Charge

Claims Cost

Frequency

Amount

of per

of per

Per Capita
Monthly

Per Capita
Monthly

Service

Service

Cost Sharing

Claims Cost

Copay

Copay

Value

After Copav

Hospital Inpatient
Non-Maternity
Medical

135

$1,279.63

$14.40

0.0

$0.00

$0.00

$14.40

Surgical

142

$2,329.16

$27.46

0.0

$0.00

$0.00

$27.46

Neonatal

21

$4,658.33

$8.32

0.0

$0.00

$0.00

$8.32

Psychiatric

76

$1,215.65

$7.71

0.0

$0.00

$0.00

$7.71

Alcohol & Drug Abuse

41

$972.52

$3.30

0.0

$0.00

$0.00

$3.30

Maternity
Normal Deliveries

20

$1,192.15

$2.02

0.0

$0.00

$0.00

$2.02

Cesarean Deliveries

19

$1,943.91

$3.13

0.0

$0.00

$0.00

$3.13

Non-Deliveries

11

$1,324.19

$1.26

0.0

$0.00

$0.00

$1.26

5

$883.39

$0.39

0.0

$0.00

$0.00

$0.39

Abortions
Boarder Babies

19

$395.06

$0,64

0.0

$0.00

$0.00

$0.64

Skilled Nursing Facility

12

$214.90

$0.21

0.0

$0.00

$0.00

$0.21

Total Hospital Inpatient

502

$1,644.61

$68.85

$0.00

$68.85

Hospital Outpatient
Emergency Room

364

$182.25

$5.53

364.4

$25,00

$0.76

$4.77

Medical

139

$108.77

$1.26

0.0

$0.00

$0.00

$1,26

Surgery
Radiology

103

$718.00

$6.18

0.0

$0.00

$0,00

$6.18

170

$240.15

$3.40

0.0

$0.00

$0.00

$3.40

Pathology

184

$72.36

$1.11

0.0

$0.00

$0.00

$1.11

Other Services

253

$145.43

$3.07

0.0

$0.00

$0.00

$3,07

Maternity Non-Deliveries

7

$210.90

$0.13

0.0

$0.00

$0.00

$0.13

Total Hospital Outpatient

1,221

$203.26

$20.68

$0.76

$19.92

106

$624.82

$5.53

0.0

$0.00

$0.00

$5.53

14

$124.96

$0.15

0.0

$0.00

$0.00

$0.15

68

$109.90

$0.63

0.0

$0.00

$0.00

$0.63

$2.02

Physician

Inpatient Surgery
Primary Surgeon
Assistant Surgeon
Anesthesia

Outpatient Surgery
86

$282.99

$2.02

0.0

$0.00

$0.00

Surgical Center

1 16

$239.72

$2.31

0.0

$0.00

$0.00

$2.31

Office

253

$125.01

$2.64

0.0

$0,00

$0.00

$2.64

53

$88.71

$0.39

0.0

$0.00

$0.00

$0,39

OP Hospital

Anesthesia

Maternity
Normal Deliveries

6

$484.84

$0.26

0.0

$0.00

$0.00

$0.26

Cesarean Deliveries

3

$1,126.14

$0.25

0,0

$0.00

$0.00

$0.25

Non-Deliveries

5

$196.33

$0.09

0.0

$0.00

$0.00

$0.09

409

$154.71

$5.27

0.0

$0.00

$0.00

$5.27

6

$105.52

$0.05

0.0

$0.00

$0.00

$0.05

$200.28

$0.31

0.0

$0.00

$0.00

$0.31

Inpatient Visits

Hospital Visits
Extended Care Visits
Critical Care Visits

Exhibit VII

Santa Clara Family Health Plan
Small Group Insurance Program
Base Cost Assumptions
Frequency

Amount

Per Capita

of per

of per

Monthly

Per Capita
Monthly

Average

Per Capita
Monthly

Service

Service

Cost Sharing

Claims Cost

Charge

Claims Cost

Copay

Copay

Value

After Copay

5.251

$57.04

$24.96

5,250.6

$5.00

$2.19

$22.77

2

$89.13

$0.01

1.6

$5.00

$0.00

$0.01

Therapeutic Injections
Allergy Testing

129

$70.34

$0.75

128.8

$5.00

$0.05

$0.70

26

$39.93

$0.09

25.9

$5.00

$0.01

$0.08

Allergy Immunotherapy
Diagnostic Testing

239

$10.51

$0.21

239.4

$5.00

$0.10

$0.11

79

$74.07

$0.49

0.0

$0.00

$0.00

$0.49

Frequency
per 1000
Members

Office Visits
Home Visits

Physician (Continued)
Office Visits & Misc. Services

Emergency Room Visits

316

$140.44

$3.70

0.0

$0.00

$0.00

$3.70

Consultations

106

$142.01

$1.26

106.1

$5.00

$0.04

$1.21

Physical Medicine

334

$30.51

$0.85

333.9

$5.00

$0.14

$0.71

Occupational Therapy
Speech Therapy
Chiropractor
Urgent Care

276

$47.93

$1.10

275.9

$5.00

$0.1 1

$0.99

10

$93.03

$0.07

9.6

$5.00

$0.00

$0.07

0

$26.61

$0.00

0.0

$5.00

$0.00

$0.00

1,155

$98.31

$9.46

1,155.0

$5.00

$0.48

$8.98

Total Physician

9,066

$81.29

$62.84

$3.14

$59.71

Radiology
IP (Professional)

137

$67.53

$0.77

0.0

$0.00

$0.00

$0.77

OP (Professional)

337

$89.27

$2.51

0.0

$0.00

$0.00

$2.51

Office (Combined)

494

$98.86

$4.07

0.0

$0.00

$0.00

$4.07

MRI

3

$796.84

$0.20

0.0

$0.00

$0.00

$0.20

CT-Scan

2

$479.85

$0.08

0.0

$0.00

$0.00

$0.08

972

$93.99

$7.61

$0.00

$7.61

Total Radiology
Pathology
IP (Professional)
OP (Professional)

66

$21.19

$0.12

0.0

$0.00

$0.00

$0.12

125

$32.95

$0.34

0.0

$0.00

$0.00

$0.34

Office (Combined)

3,059

$35.77

$9.12

0.0

$0.00

$0.00

$9.12

Total Pathology

3,250

$35.36

$9.58

$0.00

$9.58

$28.91

Other Services

9,170

$42.83

$32.73

9,170.1

$5.00

$3.82

PDN/Homc Health Care

32

$50.18

$0.13

0.0

$0.00

$0.00

$0.13

Ambulance

15

$71.37

$0.09

0.0

$0.00

$0.00

$0.09

Durable Medical Equipment

29

$103.13

$0.25

0.0

$0.00

$0.00

$0.25

3

$318.54

$0.09

0.0

$0.00

$0.00

$0.09

9,249

$43.18

$33,29

$3.82

$29.47

Prescription Drugs

Prosthetics

Total Other Services

Exhibit VII

Santa Clara Family Health Plan
Small Group Insurance Program
Base Cost Assumptions
Frequency
per 1000

Average

Per Capita
Monthly

Members

Charge

Claims Cost

Frequency
of per

Amount

Per Capita

Per Capita

of per

Service

Service

Monthly
Cost Sharing

Claims Cost

Conav

Copav

Value

After Copav

Monthly

Additional Services
Immunizations

Physical Exams

401

$35.79

$1.20

0.0

$0.00

$0.00

$1.20

94

$59.26

$0.46

0.0

$0.00

$0.00

$0.46

Well Woman Exams

195

$59.26

$0.96

0.0

$0.00

$0.00

$0.96

Vision Exams

262

$53.49

$1.17

0.0

$0.00

$0.00

$1.17

Speech Exams

210

$90.21

$1.58

0.0

$0.00

$0.00

$1.58

4

$62.31

$0.02

0.0

$0.00

$0.00

$0.02

105

$264.81

$2.32

0.0

$0.00

$0.00

$2.32

4

$45.89

$0.02

0.0

$0.00

$0.00

$0.02

Abortions

4

$83.67

$0.03

4.3

$5.00

$0.00

$0.03

Podiatrist

60

$78.29

$0.39

60.1

$5.00

$0.03

$0.37

203

$162.49

$2.75

203.0

$5.00

$0.08

$2.66

30

$117.50

$0.30

30.2

$5.00

$0.01

$0.28

1,574

$85.35

$11.19

$0.12

$11.07

25,834

$99.47

$214.05

$7.84

$206.21

Hearing Exams
Hearing Aids
Family Planning

OP Psychiatric
OP Alcohol & Drug Abuse
Total Additional Setv'ices

Total All Services

Cost with Administrative Loading

$229.12