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["Completeness  Checklist"]
[]
["Instructions for Completion Checklist"]
["This checklist should be completed by all issuers submitting Student Health Plan rates and should be submitted, as supporting documentation, with each Student Health Plan Insurance rate filing.   The checklist is organized by heading, section and subsection as outlined in the Final Student Health Insurance Rate Filing Guidance (Guidance). "]
["\"Completed\" Column\nThe first input column is labeled “Completed”.  In order for the filing to be considered complete and ready for department review, üshould appear in each field in the column, except where data tables are marked “if applicable”.  The ü indicates that the actuary has read the Guidance and has provided all of the requested information and data, as indicated in the Guidance.  \n"]
["\"Requirement\" Columns\nThe “Requirement” section contains three columns.  If the issuer’s filing contains the required information or data in the named section, “Y” must be populated in the \"Certified\" column.   If an \"N\" appears in this column, the filing will be rejected.\n\nEach issuer must submit a \"Public Rate Filing PDF\" with the final version that will be acknowledged.   The PDF document must contain all required documents, tables and exhibits. If the issuers chooses to make the limited redactions anticipated by the Department, as indicated on page 5 of the Guidance, those redactions should be made only in this document. The \"Page #\" section should reference the page number where the information and/or data can be located."]
["If any necessary information is missing, the filing may be held until the Department has enough information to make a determination on the filing.  Correspondingly, the “Certified” column should be populated with a \"Y\" in any rows for all necessary data and information.  \nTo reiterate the redaction criteria contained in the Guidance, only information that is trade secret or confidential commercial or financial information as defined in HHS’s Freedom of Information Act (FOIA) regulations at 45 CFR§ 5.65 may be redacted.  Consistent with prior guidance, the Department does not anticipate redactions other than the following items: \n    1. AV screenshots\n    2. Statements specifying a company’s anticipated risk level in relation to the state average risk level (e.g., the underlined portion could be redacted in the following statement: “we expect the risk level of \n         membership to be X% higher/lower than the state average risk level”)\n    3. Opining actuary’s name \n    4. Specific provider contracting information (note: such information was not submitted in prior rate     \n         filings and the department does not anticipate receiving such information in plan year 2019 rate filings)\n    5. Commission schedules\n\n Please remain cognizant that non-redacted information and data should be submitted for review.\n"]
["You may contact Dave Yanick at dyanick@pa.gov if you have any questions regarding this checklist."]

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["Issuer Name:"]
["Market:"]
["SERFF ID: "]
[]
["TOC #","Description","Completed\nMark with ü","Requirement "]
[null,null,null,"Certified","Page # ","Comments"]
["Summary Documents/Confirmation of SERFF Submissions"]
["B.2.B.","SERFF Submission"]
["B.2.C.","SERFF Rate/Rule Schedule Tab"]
["C.","Cover Letter "]
["PA Rate Manual Filing"]
["D.1.","Rate Manual"]
["D.2.","Actuarial Memorandum"]
["D.2.1.","     Summary Information"]
["D.2.2.","     Benefits"]
["D.2.3.","     Risk Pool Identification & Descriptions"]
["D.2.4.","     Base Rate Development"]
["D.2.5.","     Trend Identification & Justification"]
["D.2.6.","     Credibility of Data"]
["D.2.7.","     Manual Data"]
["D.2.8.","     Completion Factors"]
["D.2.9.","     Retention, Taxes and Fees"]
["D.2.10.","     Loss Ratio Demonstration"]
["D.2.11.","     Plan & Network Factors"]
["D.2.12.","     Guaranteed Renewability"]
["D.2.13.","     Guaranteed Availability"]
["D.2.14.","     Final Rate Development Method"]
["Group Specific Named Filing"]
["E.1","     Cover Letter"]
["E.2","     RRJ"]
["E.3","     AV Screenshot"]
["E.4","     Excel Based Rate Development for School"]
["E.5","     Final Rates"]
["E.5.b.","     Community Rate Schools"]
["E.5.b.i","     Family Development Factors"]
["E.5.b.ii","     Geographic Rating Factors (consistent with other ACA products)"]
["E.5.b.iii","     Age Factors (3:1)"]
["F.","     Actuarial Certifications"]
["G. ","     RRJ Part II Written Explanation of Rate Change"]
["Additional Checklist Certifications"]
[null,"Actuarial Value\nAV levels specified in Part 156 do not apply. Student health coverage must provide at least 60 \npercent actuarial value, as calculated in accordance with\n§156.135. The issuer must specify in any plan materials summarizing the terms of the coverage the\n actuarial value and level of coverage (or next lowest  level of coverage) the coverage would otherwise satisfy under §156.140.\n"]
[null,"Essential Health Benefits (EH\nEHBs, which include items and services within at least the following 10 categories:\n1. Ambulatory patient services\n2. Emergency services\n3. Hospitalization\n4. Maternity and newborn care\n5. Mental health and substance use disorder services, including behavioral health treatment\n6. Prescription drugs\n7. Rehabilitative and habilitative services and devices\n8. Laboratory services\n9. Preventive and wellness services and chronic disease management\n10. Pediatric services, including oral and vision care\n\n"]
[null,"Single Risk Pool Development                                                                          With respect to the single risk pool for a particular college, the issuer is required to provide support that the single risk pool in a particular institution and market is established according to the requirements in 45 CFR 156.80. The single risk pool reflects all covered lives for every non-grandfathered product/plan combination for an issuer in a State and market. The single risk pool is specific to the legal entity for the State and market for which it is submitted."]
[null,"Fair health insurance premiums                                                                          With respect to the premium rate charged for a particular plan or coverage, the only rating factors allowed:                                                      1. Family (generally per-member build-up; 3-covered child cap                                                  under age 21)                                                                                                                2. Geographic rating area                                                                                                                                                                                                                             3. Age (3:1)                                                                                                                                                                                                                                                                                                                     "]
[null,"Prohibiting discrimination against participants and beneficiaries based on a health factor\nIssuers may not establish any rule for eligibility (including continued eligibility) of any individual to enroll for benefits under the terms of the plan or group health insurance coverage that discriminates based on any health factor that relates to that individual or a dependent of that individual.\nIssuers may not require any individual (as a condition of enrollment or continued enrollment under the plan) to pay a premium or contribution which is greater than such premium or contribution for a similarly situated individual enrolled in the plan on the basis of any health status-related factor in relation to the individual or to an individual enrolled under the plan as a dependent of the individual.                                                                                                                                                                                                                                                                                                   "]
[null,"Certification that final rates are developed in accordance with the approved rate manual"]