Rate Guide 2021 Individual and Family Plans · 2020. 12. 21. · Rate Guide 2021 Individual and...
Transcript of Rate Guide 2021 Individual and Family Plans · 2020. 12. 21. · Rate Guide 2021 Individual and...
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Rate Guide 2021 Individual and Family Plans
Member Services 1-855-315-5800 | sutterhealthplus.org B-20-034
http://sutterhealthplus.org
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Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 (3) MI04 Age Platinum Gold Silver Bronze
0-14 $449.32 $386.23 $343.01 $256.12
15 $489.26 $420.56 $373.50 $278.89
16 $504.53 $433.69 $385.16 $287.59
17 $519.80 $446.81 $396.82 $296.30
18 $536.25 $460.95 $409.37 $305.67
19 $552.69 $475.09 $421.93 $315.04
20 $569.73 $489.73 $434.93 $324.75
21 $587.36 $504.89 $448.39 $334.81
22 $587.36 $504.89 $448.39 $334.81
23 $587.36 $504.89 $448.39 $334.81
24 $587.36 $504.89 $448.39 $334.81
25 $589.70 $506.89 $450.17 $336.14
26 $601.44 $516.99 $459.14 $342.83
27 $615.54 $529.11 $469.90 $350.87
28 $638.45 $548.80 $487.39 $363.93
29 $657.24 $564.96 $501.74 $374.64
30 $666.64 $573.03 $508.91 $380.00
31 $680.74 $585.15 $519.67 $388.03
32 $694.83 $597.27 $530.43 $396.07
33 $703.64 $604.84 $537.16 $401.09
34 $713.04 $612.92 $544.33 $406.44
35 $717.74 $616.96 $547.92 $409.12
36 $722.44 $621.00 $551.51 $411.80
Sutter Health Plus Rate Guide Thank you for considering Sutter Health Plus as your health plan partner. This guide can help you find Individual and Family Plan (IFP) monthly premiums and select the right plan to fit your budget.
IFP Rates As an IFP member, you must pay a monthly premium to Sutter Health Plus for health care coverage. Your monthly premium is based on the plan you select, the age of each covered member as of the coverage effective date, the ZIP code where you live or reside, and if you are obtaining individual or family coverage. IFP plans follow a calendar year cycle—January 1 to December 31—and always renew on January 1 regardless of the original coverage effective date.
Use the following steps to calculate your monthly premium.
For Yourself 1. Find your county, ZIP code and rating region using the map on page 4.
2. Use your age as of your coverage effective date.*
3. Select a plan.
4. Calculate monthly premium.
Example: A 36 year old in Region 3 on the Silver MI03 HMO plan.
Rating Region 3 El Dorado (partial), Placer (partial), Sacramento and Yolo Counties
(4) (2)
*For example, if you enroll with Sutter Health Plus with a coverage effective date of March 1 for your first year, then we use your age as of March 1. When your coverage renews on January 1 of the following year, we base your renewal rate on your age as of January 1.
Page 2 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 (3) MI04 Age Platinum Gold Silver Bronze
0-14 - child #1 $474.75 $408.09 $362.42 $271.98
15 - child #2 (2) $516.95 $444.36 $394.64 (4) $296.16 16 $533.09 $458.23 $406.96 $305.40
17 $549.22 $472.10 $419.28 $314.65
18 - child #3 (2) $566.60 $487.04 $432.54 (4) $324.60 19 $583.97 $501.98 $445.81 $334.56
20 - child #4 (2) $601.97 $517.45 $459.55 (4) $344.87 21 $620.60 $533.46 $473.77 $355.54
22 $620.60 $533.46 $473.77 $355.54
23 $620.60 $533.46 $473.77 $355.54
24 $620.60 $533.46 $473.77 $355.54
25 $623.07 $535.58 $475.65 $356.95
26 $635.48 $546.25 $485.13 $364.07
27 $650.38 $559.06 $496.50 $372.60
28 $674.58 $579.86 $514.97 $386.46
29 $694.44 $596.93 $530.14 $397.84
30 $704.37 $605.47 $537.72 $403.53
31 $719.26 $618.27 $549.09 $412.06
32 $734.16 $631.07 $560.46 $420.59
33 $743.47 $639.07 $567.56 $425.93
34 - your spouse (2) $753.40 $647.61 $575.14 (4) $431.62 35 $758.36 $651.88 $578.93 $434.46
36 $763.33 $656.14 $582.72 $437.30
37 - you $768.29 $660.41 $586.51 $440.15
Totals Child #1 —
Child #2 $394.64
Child #3 $432.54
Child #4 $459.55
Your spouse $575.14
You $586.51
Total Monthly Premium: $2,448.38
For a Family 1. Find your county, ZIP code and rating region using
the map on page 4.
2. Use each enrolling family member’s age as of the coverage effective date:*
• You
• Your spouse or domestic partner
• Adult children ages 21 through 25
• Your three oldest children under age 21
El Dorado (partial), Placer (partial), Sacramento and Yolo Counties
Example: A family of four in Region 3 on the Silver MI03 HMO plan.
3. Select a plan.
4. Calculate the monthly premium for each family member.
• If you have more than three children under the age of 21, you will only pay premiums for the three oldest
• If you have more than three children and the oldest turns 21 during the current plan year, the rates will be adjusted at the next renewal
Rating Region 3
(4) (2)
If you have any questions or need assistance with this rate guide, please call Sutter Health Plus Member Services at 1-855-315-5800 Monday through Friday, 8 a.m. to 7 p.m.
*For example, if you enroll with Sutter Health Plus with a coverage effective date of March 1 for your first year, then we use your age as of March 1. When your coverage renews on January 1 of the following year, we base your renewal rate on your age as of January 1.
Page 3 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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YOLO
SUTTER
SOLANO
SONOMA
SAN MATEO
SAN FRANCISCO
SANTA CRUZ
SAN JOAQUIN
STANISLAUS
SACRAMENTO
EL DORADO
ALAMEDA
PLACER
CONTRA COSTA
SANTA CLARA
Licensed Service Area
In Service Area
Out of Service Area
Alameda County Region 6 - Page 10 All ZIP codes
Contra Costa County Region 5 - Page 9 All ZIP codes
El Dorado County (partial) Region 3 - Page 7 95614 95635 95651 95664 95672 95682 95762
Placer County (partial) Region 3 - Page 7 95602 95603 95648 95650 95658 95661 95663 95677
95678 95681 95703 95713 95722 95746 95747 95765
Sacramento County Region 3 - Page 7 All ZIP codes
San Francisco County Region 4 - Page 8 All ZIP codes
San Joaquin County Region 10 - Page 14 All ZIP codes
San Mateo County Region 8 - Page 12 All ZIP codes
Santa Clara County (partial) Region 7 - Page 11 94022 94024 94040 94041 94043 94085 94086 94087
94089 94301 94303 94304 94305 94306 95002 95008
95013 95014 95030 95032 95033 95035 95050 95051
95053 95054 95070 95076 95110 95111 95112 95113
95116 95117 95118 95119 95120 95121 95122 95123
95124 95125 95126 95127 95128 95129 95130 95131
95132 95133 95134 95135 95136 95138 95139 95140
95148 95192
Santa Cruz County Region 9 - Page 13 All ZIP codes
Stanislaus County Region 10 - Page 14 All ZIP codes
Solano County Region 2 - Page 6 All ZIP codes
Sonoma County (partial) Region 2 - Page 6 94926 94927 94928 94931 94951 94952 94953 94954
94955 94972 94975 94999 95401 95402 95403 95404
95405 95406 95407 95409 95419 95421 95425 95430
95436 95439 95441 95442 95444 95446 95448 95450
95452 95462 95465 95471 95472 95473 95486 95492
Sutter County (partial) Region 1 - Page 5 95645 95668 95659
Yolo County Region 3 - Page 7 All ZIP codes
Some ZIP codes span more than one county. In that case, both the ZIP code and the county must be within the licensed service area for a member to enroll.
Page 4 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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Sutter County (partial)
Rating Region 1
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $484.85 $416.77 $370.13 $277.77
15 $527.95 $453.81 $403.03 $302.46
16 $544.42 $467.98 $415.61 $311.90
17 $560.90 $482.14 $428.19 $321.34
18 $578.65 $497.40 $441.74 $331.50
19 $596.39 $512.65 $455.29 $341.67
20 $614.77 $528.45 $469.32 $352.20
21 $633.80 $544.81 $483.84 $363.10
22 $633.80 $544.81 $483.84 $363.10
23 $633.80 $544.81 $483.84 $363.10
24 $633.80 $544.81 $483.84 $363.10
25 $636.32 $546.97 $485.77 $364.55
26 $649.00 $557.87 $495.45 $371.81
27 $664.21 $570.95 $507.06 $380.52
28 $688.93 $592.19 $525.93 $394.68
29 $709.21 $609.63 $541.41 $406.30
30 $719.35 $618.34 $549.15 $412.11
31 $734.56 $631.42 $560.76 $420.83
32 $749.77 $644.49 $572.38 $429.54
33 $759.28 $652.67 $579.63 $434.99
34 $769.42 $661.38 $587.37 $440.80
35 $774.49 $665.74 $591.24 $443.70
36 $779.56 $670.10 $595.12 $446.61
37 $784.63 $674.46 $598.99 $449.51
38 $789.70 $678.82 $602.86 $452.41
39 $799.84 $687.53 $610.60 $458.22
40 $809.98 $696.25 $618.34 $464.03
41 $825.19 $709.32 $629.95 $472.75
42 $839.77 $721.85 $641.08 $481.10
43 $860.05 $739.29 $656.56 $492.72
44 $885.40 $761.08 $675.92 $507.24
45 $915.19 $786.68 $698.66 $524.31
46 $950.68 $817.19 $725.75 $544.64
47 $990.61 $851.52 $756.23 $567.52
48 $1,036.24 $890.74 $791.07 $593.66
49 $1,081.24 $929.42 $825.42 $619.44
50 $1,131.95 $973.00 $864.13 $648.49
51 $1,182.02 $1,016.04 $902.35 $677.17
52 $1,237.15 $1,063.44 $944.44 $708.76
53 $1,292.93 $1,111.38 $987.02 $740.71
54 $1,353.14 $1,163.14 $1,032.98 $775.21
55 $1,413.35 $1,214.89 $1,078.95 $809.70
56 $1,478.63 $1,271.01 $1,128.78 $847.10
57 $1,544.54 $1,327.67 $1,179.10 $884.86
58 $1,614.89 $1,388.14 $1,232.81 $925.16
59 $1,649.75 $1,418.10 $1,259.42 $945.13
60 $1,720.10 $1,478.58 $1,313.12 $985.44
61 $1,780.95 $1,530.88 $1,359.57 $1,020.29
62 $1,820.87 $1,565.20 $1,390.05 $1,043.17
63 $1,870.94 $1,608.24 $1,428.28 $1,071.85
64-99 $1,901.35 $1,634.38 $1,451.49 $1,089.27
Page 5 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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Solano and Sonoma (partial) Counties
Rating Region 2
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $474.75 $408.09 $362.42 $271.98
15 $516.95 $444.36 $394.64 $296.16
16 $533.09 $458.23 $406.96 $305.40
17 $549.22 $472.10 $419.28 $314.65
18 $566.60 $487.04 $432.54 $324.60
19 $583.97 $501.98 $445.81 $334.56
20 $601.97 $517.45 $459.55 $344.87
21 $620.60 $533.46 $473.77 $355.54
22 $620.60 $533.46 $473.77 $355.54
23 $620.60 $533.46 $473.77 $355.54
24 $620.60 $533.46 $473.77 $355.54
25 $623.07 $535.58 $475.65 $356.95
26 $635.48 $546.25 $485.13 $364.07
27 $650.38 $559.06 $496.50 $372.60
28 $674.58 $579.86 $514.97 $386.46
29 $694.44 $596.93 $530.14 $397.84
30 $704.37 $605.47 $537.72 $403.53
31 $719.26 $618.27 $549.09 $412.06
32 $734.16 $631.07 $560.46 $420.59
33 $743.47 $639.07 $567.56 $425.93
34 $753.40 $647.61 $575.14 $431.62
35 $758.36 $651.88 $578.93 $434.46
36 $763.33 $656.14 $582.72 $437.30
37 $768.29 $660.41 $586.51 $440.15
38 $773.25 $664.68 $590.30 $442.99
39 $783.18 $673.21 $597.88 $448.68
40 $793.11 $681.75 $605.46 $454.37
41 $808.01 $694.55 $616.83 $462.90
42 $822.28 $706.82 $627.73 $471.08
43 $842.14 $723.89 $642.89 $482.46
44 $866.96 $745.23 $661.84 $496.68
45 $896.13 $770.30 $684.11 $513.39
46 $930.88 $800.18 $710.64 $533.30
47 $969.98 $833.78 $740.48 $555.70
48 $1,014.66 $872.19 $774.59 $581.30
49 $1,058.73 $910.07 $808.23 $606.54
50 $1,108.37 $952.74 $846.13 $634.98
51 $1,157.40 $994.88 $883.56 $663.07
52 $1,211.39 $1,041.29 $924.78 $694.00
53 $1,266.00 $1,088.24 $966.47 $725.29
54 $1,324.96 $1,138.92 $1,011.47 $759.06
55 $1,383.92 $1,189.59 $1,056.48 $792.84
56 $1,447.84 $1,244.54 $1,105.28 $829.46
57 $1,512.38 $1,300.02 $1,154.55 $866.43
58 $1,581.26 $1,359.23 $1,207.14 $905.90
59 $1,615.40 $1,388.57 $1,233.19 $925.45
60 $1,684.28 $1,447.78 $1,285.78 $964.92
61 $1,743.86 $1,499.00 $1,331.26 $999.05
62 $1,782.95 $1,532.60 $1,361.11 $1,021.44
63 $1,831.98 $1,574.75 $1,398.53 $1,049.53
64-99 $1,861.76 $1,600.34 $1,421.26 $1,066.59
Page 6 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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El Dorado (partial), Placer (partial), Sacramento and Yolo Counties
Rating Region 3
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $449.32 $386.23 $343.01 $257.41
15 $489.26 $420.56 $373.50 $280.29
16 $504.53 $433.69 $385.16 $289.04
17 $519.80 $446.81 $396.82 $297.79
18 $536.25 $460.95 $409.37 $307.21
19 $552.69 $475.09 $421.93 $316.64
20 $569.73 $489.73 $434.93 $326.39
21 $587.36 $504.89 $448.39 $336.50
22 $587.36 $504.89 $448.39 $336.50
23 $587.36 $504.89 $448.39 $336.50
24 $587.36 $504.89 $448.39 $336.50
25 $589.70 $506.89 $450.17 $337.83
26 $601.44 $516.99 $459.14 $344.56
27 $615.54 $529.11 $469.90 $352.64
28 $638.45 $548.80 $487.39 $365.76
29 $657.24 $564.96 $501.74 $376.53
30 $666.64 $573.03 $508.91 $381.91
31 $680.74 $585.15 $519.67 $389.99
32 $694.83 $597.27 $530.43 $398.07
33 $703.64 $604.84 $537.16 $403.11
34 $713.04 $612.92 $544.33 $408.50
35 $717.74 $616.96 $547.92 $411.19
36 $722.44 $621.00 $551.51 $413.88
37 $727.14 $625.04 $555.09 $416.57
38 $731.83 $629.07 $558.68 $419.26
39 $741.23 $637.15 $565.86 $424.65
40 $750.63 $645.23 $573.03 $430.03
41 $764.73 $657.35 $583.79 $438.11
42 $778.23 $668.96 $594.10 $445.85
43 $797.03 $685.12 $608.45 $456.61
44 $820.52 $705.31 $626.39 $470.07
45 $848.13 $729.04 $647.46 $485.89
46 $881.02 $757.31 $672.57 $504.73
47 $918.02 $789.12 $700.82 $525.93
48 $960.31 $825.47 $733.10 $550.16
49 $1,002.01 $861.32 $764.94 $574.05
50 $1,049.00 $901.71 $800.81 $600.97
51 $1,095.40 $941.59 $836.23 $627.55
52 $1,146.50 $985.52 $875.24 $656.82
53 $1,198.19 $1,029.95 $914.70 $686.44
54 $1,253.99 $1,077.91 $957.29 $718.40
55 $1,309.78 $1,125.87 $999.89 $750.37
56 $1,370.28 $1,177.87 $1,046.07 $785.03
57 $1,431.36 $1,230.38 $1,092.70 $820.02
58 $1,496.56 $1,286.42 $1,142.47 $857.37
59 $1,528.86 $1,314.19 $1,167.13 $875.88
60 $1,594.06 $1,370.23 $1,216.90 $913.23
61 $1,650.44 $1,418.70 $1,259.95 $945.53
62 $1,687.45 $1,450.51 $1,288.20 $966.73
63 $1,733.85 $1,490.39 $1,323.62 $993.31
64-99 $1,762.03 $1,514.62 $1,345.13 $1,009.45
Page 7 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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San Francisco County
Rating Region 4
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $502.02 $431.53 $383.24 $287.61
15 $546.65 $469.89 $417.31 $313.17
16 $563.71 $484.56 $430.33 $322.95
17 $580.77 $499.22 $443.36 $332.72
18 $599.14 $515.02 $457.39 $343.25
19 $617.52 $530.81 $471.41 $353.77
20 $636.55 $547.17 $485.94 $364.68
21 $656.25 $564.10 $500.98 $375.96
22 $656.25 $564.10 $500.98 $375.96
23 $656.25 $564.10 $500.98 $375.96
24 $656.25 $564.10 $500.98 $375.96
25 $658.86 $566.35 $502.98 $377.46
26 $671.99 $577.63 $512.99 $384.98
27 $687.74 $591.17 $525.02 $394.00
28 $713.33 $613.17 $544.56 $408.66
29 $734.33 $631.22 $560.59 $420.69
30 $744.83 $640.25 $568.60 $426.71
31 $760.58 $653.78 $580.63 $435.73
32 $776.33 $667.32 $592.65 $444.75
33 $786.17 $675.78 $600.16 $450.39
34 $796.67 $684.81 $608.18 $456.41
35 $801.92 $689.32 $612.19 $459.42
36 $807.17 $693.83 $616.19 $462.42
37 $812.42 $698.35 $620.20 $465.43
38 $817.67 $702.86 $624.21 $468.44
39 $828.17 $711.88 $632.23 $474.46
40 $838.67 $720.91 $640.24 $480.47
41 $854.42 $734.45 $652.26 $489.49
42 $869.51 $747.42 $663.79 $498.14
43 $890.51 $765.47 $679.82 $510.17
44 $916.76 $788.04 $699.86 $525.21
45 $947.61 $814.55 $723.40 $542.88
46 $984.36 $846.14 $751.46 $563.93
47 $1,025.70 $881.68 $783.02 $587.62
48 $1,072.95 $922.29 $819.09 $614.69
49 $1,119.54 $962.34 $854.66 $641.38
50 $1,172.04 $1,007.47 $894.74 $671.46
51 $1,223.88 $1,052.03 $934.31 $701.16
52 $1,280.98 $1,101.11 $977.90 $733.86
53 $1,338.72 $1,150.75 $1,021.98 $766.95
54 $1,401.07 $1,204.34 $1,069.57 $802.66
55 $1,463.41 $1,257.93 $1,117.17 $838.38
56 $1,531.00 $1,316.03 $1,168.77 $877.10
57 $1,599.25 $1,374.69 $1,220.87 $916.20
58 $1,672.09 $1,437.31 $1,276.48 $957.93
59 $1,708.19 $1,468.33 $1,304.03 $978.61
60 $1,781.03 $1,530.95 $1,359.64 $1,020.34
61 $1,844.03 $1,585.10 $1,407.73 $1,056.43
62 $1,885.37 $1,620.64 $1,439.29 $1,080.12
63 $1,937.21 $1,665.20 $1,478.87 $1,109.82
64-99 $1,968.70 $1,692.27 $1,502.90 $1,127.85
Page 8 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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Contra Costa County
Rating Region 5
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $511.40 $439.59 $390.40 $292.98
15 $556.86 $478.67 $425.11 $319.02
16 $574.24 $493.61 $438.37 $328.98
17 $591.62 $508.55 $451.64 $338.94
18 $610.34 $524.64 $465.93 $349.66
19 $629.06 $540.73 $480.22 $360.38
20 $648.44 $557.39 $495.02 $371.49
21 $668.51 $574.64 $510.34 $382.99
22 $668.51 $574.64 $510.34 $382.99
23 $668.51 $574.64 $510.34 $382.99
24 $668.51 $574.64 $510.34 $382.99
25 $671.17 $576.93 $512.37 $384.51
26 $684.54 $588.42 $522.58 $392.17
27 $700.59 $602.21 $534.83 $401.36
28 $726.66 $624.63 $554.73 $416.30
29 $748.05 $643.01 $571.06 $428.55
30 $758.75 $652.21 $579.23 $434.68
31 $774.79 $666.00 $591.47 $443.87
32 $790.83 $679.79 $603.72 $453.06
33 $800.86 $688.41 $611.38 $458.81
34 $811.56 $697.60 $619.54 $464.94
35 $816.91 $702.20 $623.63 $468.00
36 $822.25 $706.80 $627.71 $471.06
37 $827.60 $711.39 $631.79 $474.13
38 $832.95 $715.99 $635.87 $477.19
39 $843.65 $725.19 $644.04 $483.32
40 $854.34 $734.38 $652.20 $489.45
41 $870.39 $748.17 $664.45 $498.64
42 $885.76 $761.39 $676.19 $507.45
43 $907.15 $779.78 $692.52 $519.70
44 $933.89 $802.76 $712.93 $535.02
45 $965.31 $829.77 $736.92 $553.02
46 $1,002.75 $861.95 $765.50 $574.47
47 $1,044.86 $898.15 $797.65 $598.60
48 $1,093.00 $939.52 $834.39 $626.17
49 $1,140.46 $980.32 $870.63 $653.36
50 $1,193.94 $1,026.29 $911.45 $684.00
51 $1,246.75 $1,071.69 $951.77 $714.26
52 $1,304.91 $1,121.68 $996.17 $747.58
53 $1,363.74 $1,172.25 $1,041.08 $781.28
54 $1,427.24 $1,226.84 $1,089.56 $817.66
55 $1,490.75 $1,281.43 $1,138.04 $854.04
56 $1,559.61 $1,340.62 $1,190.60 $893.49
57 $1,629.13 $1,400.38 $1,243.68 $933.32
58 $1,703.33 $1,464.16 $1,300.33 $975.83
59 $1,740.10 $1,495.77 $1,328.39 $996.90
60 $1,814.31 $1,559.55 $1,385.04 $1,039.41
61 $1,878.48 $1,614.72 $1,434.03 $1,076.17
62 $1,920.60 $1,650.92 $1,466.18 $1,100.30
63 $1,973.41 $1,696.31 $1,506.50 $1,130.55
64-99 $2,005.49 $1,723.89 $1,530.99 $1,148.93
Page 9 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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Alameda County
Rating Region 6
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $463.29 $398.23 $353.67 $265.41
15 $504.47 $433.63 $385.11 $289.01
16 $520.21 $447.17 $397.13 $298.03
17 $535.96 $460.70 $409.15 $307.05
18 $552.91 $475.28 $422.09 $316.76
19 $569.87 $489.85 $435.04 $326.48
20 $587.43 $504.95 $448.45 $336.54
21 $605.61 $520.58 $462.33 $346.96
22 $605.61 $520.58 $462.33 $346.96
23 $605.61 $520.58 $462.33 $346.96
24 $605.61 $520.58 $462.33 $346.96
25 $608.02 $522.65 $464.17 $348.33
26 $620.14 $533.06 $473.41 $355.27
27 $634.67 $545.55 $484.51 $363.60
28 $658.29 $565.86 $502.54 $377.13
29 $677.67 $582.51 $517.33 $388.23
30 $687.36 $590.84 $524.73 $393.78
31 $701.89 $603.34 $535.82 $402.11
32 $716.43 $615.83 $546.92 $410.44
33 $725.51 $623.64 $553.86 $415.64
34 $735.20 $631.97 $561.25 $421.19
35 $740.05 $636.13 $564.95 $423.97
36 $744.89 $640.30 $568.65 $426.74
37 $749.74 $644.46 $572.35 $429.52
38 $754.58 $648.63 $576.05 $432.29
39 $764.27 $656.96 $583.44 $437.85
40 $773.96 $665.28 $590.84 $443.40
41 $788.49 $677.78 $601.94 $451.72
42 $802.42 $689.75 $612.57 $459.70
43 $821.80 $706.41 $627.36 $470.81
44 $846.03 $727.23 $645.86 $484.68
45 $874.49 $751.70 $667.58 $500.99
46 $908.40 $780.85 $693.47 $520.42
47 $946.56 $813.65 $722.60 $542.28
48 $990.16 $851.13 $755.89 $567.26
49 $1,033.16 $888.09 $788.71 $591.89
50 $1,081.61 $929.73 $825.70 $619.65
51 $1,129.45 $970.86 $862.22 $647.05
52 $1,182.14 $1,016.15 $902.44 $677.24
53 $1,235.43 $1,061.96 $943.13 $707.77
54 $1,292.96 $1,111.41 $987.05 $740.73
55 $1,350.49 $1,160.86 $1,030.97 $773.69
56 $1,412.87 $1,214.48 $1,078.58 $809.43
57 $1,475.85 $1,268.62 $1,126.66 $845.51
58 $1,543.07 $1,326.40 $1,177.98 $884.02
59 $1,576.38 $1,355.04 $1,203.41 $903.10
60 $1,643.60 $1,412.82 $1,254.73 $941.61
61 $1,701.74 $1,462.79 $1,299.11 $974.92
62 $1,739.89 $1,495.59 $1,328.23 $996.78
63 $1,787.74 $1,536.71 $1,364.76 $1,024.18
64-99 $1,816.80 $1,561.69 $1,386.94 $1,040.83
Page 10 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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Santa Clara County (partial)
Rating Region 7
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $534.41 $459.38 $407.97 $306.16
15 $581.92 $500.21 $444.24 $333.38
16 $600.08 $515.82 $458.10 $343.78
17 $618.24 $531.43 $471.97 $354.19
18 $637.80 $548.25 $486.90 $365.39
19 $657.36 $565.06 $501.83 $376.60
20 $677.62 $582.48 $517.30 $388.21
21 $698.59 $600.50 $533.31 $400.22
22 $698.59 $600.50 $533.31 $400.22
23 $698.59 $600.50 $533.31 $400.22
24 $698.59 $600.50 $533.31 $400.22
25 $701.38 $602.89 $535.43 $401.81
26 $715.35 $614.90 $546.10 $409.82
27 $732.11 $629.31 $558.89 $419.42
28 $759.36 $652.73 $579.69 $435.03
29 $781.71 $671.95 $596.76 $447.84
30 $792.89 $681.56 $605.29 $454.24
31 $809.66 $695.97 $618.09 $463.85
32 $826.42 $710.38 $630.89 $473.45
33 $836.90 $719.39 $638.89 $479.46
34 $848.08 $729.00 $647.42 $485.86
35 $853.67 $733.80 $651.69 $489.06
36 $859.25 $738.60 $655.95 $492.26
37 $864.84 $743.41 $660.22 $495.46
38 $870.43 $748.21 $664.49 $498.67
39 $881.61 $757.82 $673.02 $505.07
40 $892.79 $767.43 $681.55 $511.47
41 $909.55 $781.84 $694.35 $521.08
42 $925.62 $795.65 $706.62 $530.28
43 $947.97 $814.87 $723.68 $543.09
44 $975.92 $838.89 $745.02 $559.10
45 $1,008.75 $867.11 $770.08 $577.91
46 $1,047.87 $900.74 $799.94 $600.32
47 $1,091.88 $938.57 $833.54 $625.53
48 $1,142.18 $981.80 $871.94 $654.35
49 $1,191.78 $1,024.44 $909.80 $682.76
50 $1,247.67 $1,072.48 $952.47 $714.78
51 $1,302.85 $1,119.92 $994.60 $746.40
52 $1,363.63 $1,172.16 $1,041.00 $781.22
53 $1,425.11 $1,225.00 $1,087.93 $816.44
54 $1,491.47 $1,282.05 $1,138.59 $854.46
55 $1,557.84 $1,339.09 $1,189.25 $892.48
56 $1,629.79 $1,400.94 $1,244.18 $933.70
57 $1,702.44 $1,463.40 $1,299.64 $975.32
58 $1,779.99 $1,530.05 $1,358.84 $1,019.74
59 $1,818.41 $1,563.08 $1,388.17 $1,041.76
60 $1,895.95 $1,629.73 $1,447.37 $1,086.18
61 $1,963.01 $1,687.38 $1,498.56 $1,124.60
62 $2,007.02 $1,725.21 $1,532.16 $1,149.81
63 $2,062.21 $1,772.65 $1,574.29 $1,181.43
64-99 $2,095.73 $1,801.46 $1,599.88 $1,200.63
Page 11 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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San Mateo County
Rating Region 8
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $482.55 $414.79 $368.37 $276.45
15 $525.44 $451.66 $401.12 $301.02
16 $541.84 $465.76 $413.64 $310.42
17 $558.24 $479.85 $426.16 $319.81
18 $575.90 $495.04 $439.64 $329.93
19 $593.56 $510.22 $453.12 $340.05
20 $611.85 $525.94 $467.09 $350.53
21 $630.79 $542.22 $481.55 $361.38
22 $630.79 $542.22 $481.55 $361.38
23 $630.79 $542.22 $481.55 $361.38
24 $630.79 $542.22 $481.55 $361.38
25 $633.30 $544.38 $483.46 $362.81
26 $645.92 $555.22 $493.09 $370.04
27 $661.06 $568.23 $504.65 $378.71
28 $685.66 $589.38 $523.43 $392.81
29 $705.84 $606.73 $538.84 $404.37
30 $715.93 $615.41 $546.54 $410.15
31 $731.07 $628.42 $558.10 $418.83
32 $746.21 $641.43 $569.66 $427.50
33 $755.67 $649.56 $576.88 $432.92
34 $765.76 $658.24 $584.58 $438.70
35 $770.81 $662.58 $588.44 $441.59
36 $775.86 $666.92 $592.29 $444.48
37 $780.90 $671.25 $596.14 $447.38
38 $785.95 $675.59 $599.99 $450.27
39 $796.04 $684.27 $607.70 $456.05
40 $806.13 $692.94 $615.40 $461.83
41 $821.27 $705.95 $626.96 $470.50
42 $835.78 $718.43 $638.03 $478.81
43 $855.97 $735.78 $653.44 $490.38
44 $881.20 $757.46 $672.71 $504.83
45 $910.84 $782.95 $695.34 $521.82
46 $946.17 $813.31 $722.30 $542.05
47 $985.91 $847.47 $752.64 $564.82
48 $1,031.32 $886.51 $787.31 $590.84
49 $1,076.11 $925.01 $821.50 $616.50
50 $1,126.57 $968.38 $860.02 $645.41
51 $1,176.40 $1,011.22 $898.06 $673.95
52 $1,231.28 $1,058.39 $939.96 $705.39
53 $1,286.79 $1,106.10 $982.33 $737.19
54 $1,346.71 $1,157.61 $1,028.08 $771.52
55 $1,406.63 $1,209.12 $1,073.82 $805.85
56 $1,471.60 $1,264.97 $1,123.42 $843.07
57 $1,537.21 $1,321.36 $1,173.50 $880.66
58 $1,607.22 $1,381.55 $1,226.95 $920.77
59 $1,641.91 $1,411.37 $1,253.44 $940.64
60 $1,711.93 $1,471.55 $1,306.89 $980.76
61 $1,772.49 $1,523.60 $1,353.12 $1,015.45
62 $1,812.22 $1,557.76 $1,383.45 $1,038.21
63 $1,862.06 $1,600.60 $1,421.49 $1,066.76
64-99 $1,892.32 $1,626.61 $1,444.60 $1,084.10
Page 12 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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Santa Cruz County
Rating Region 9
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $471.02 $404.88 $359.58 $269.84
15 $512.89 $440.87 $391.54 $293.83
16 $528.89 $454.63 $403.76 $303.00
17 $544.90 $468.39 $415.98 $312.17
18 $562.14 $483.21 $429.14 $322.05
19 $579.38 $498.03 $442.30 $331.93
20 $597.24 $513.38 $455.93 $342.15
21 $615.72 $529.27 $470.04 $352.75
22 $615.72 $529.27 $470.04 $352.75
23 $615.72 $529.27 $470.04 $352.75
24 $615.72 $529.27 $470.04 $352.75
25 $618.17 $531.37 $471.91 $354.15
26 $630.49 $541.96 $481.31 $361.20
27 $645.26 $554.66 $492.59 $369.67
28 $669.28 $575.30 $510.93 $383.42
29 $688.98 $592.24 $525.97 $394.71
30 $698.83 $600.71 $533.49 $400.36
31 $713.61 $613.41 $544.77 $408.82
32 $728.38 $626.11 $556.05 $417.29
33 $737.62 $634.05 $563.10 $422.58
34 $747.47 $642.52 $570.62 $428.22
35 $752.40 $646.75 $574.38 $431.04
36 $757.32 $650.98 $578.14 $433.87
37 $762.25 $655.22 $581.90 $436.69
38 $767.17 $659.45 $585.66 $439.51
39 $777.03 $667.92 $593.18 $445.15
40 $786.88 $676.39 $600.70 $450.80
41 $801.65 $689.09 $611.98 $459.26
42 $815.82 $701.26 $622.79 $467.38
43 $835.52 $718.20 $637.83 $478.66
44 $860.15 $739.37 $656.64 $492.77
45 $889.09 $764.25 $678.73 $509.35
46 $923.56 $793.88 $705.05 $529.11
47 $962.35 $827.23 $734.66 $551.33
48 $1,006.69 $865.33 $768.50 $576.72
49 $1,050.40 $902.91 $801.88 $601.77
50 $1,099.66 $945.25 $839.48 $629.99
51 $1,148.30 $987.06 $876.61 $657.85
52 $1,201.87 $1,033.11 $917.50 $688.54
53 $1,256.05 $1,079.68 $958.87 $719.58
54 $1,314.54 $1,129.96 $1,003.52 $753.09
55 $1,373.03 $1,180.24 $1,048.17 $786.60
56 $1,436.45 $1,234.75 $1,096.59 $822.94
57 $1,500.49 $1,289.80 $1,145.47 $859.62
58 $1,568.83 $1,348.54 $1,197.64 $898.77
59 $1,602.69 $1,377.65 $1,223.50 $918.17
60 $1,671.04 $1,436.40 $1,275.67 $957.33
61 $1,730.14 $1,487.21 $1,320.79 $991.19
62 $1,768.93 $1,520.55 $1,350.40 $1,013.41
63 $1,817.58 $1,562.36 $1,387.54 $1,041.28
64-99 $1,847.12 $1,587.76 $1,410.09 $1,058.20
Page 13 Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
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Sutter Health Plus 2021 Individual and Family Plan Rates | Effective January 1, 2021
San Joaquin and Stanislaus Counties
Rating Region 10
Plan Name (2021) Platinum MI01 HMO (2021) Gold MI02 HMO (2021) Silver MI03 HMO (2021) Bronze MI04 HMO
Plan Number MI01 MI02 MI03 MI04
Age Platinum Gold Silver Bronze
0-14 $432.18 $371.50 $329.93 $247.60
15 $470.60 $404.52 $359.26 $269.60
16 $485.29 $417.15 $370.47 $278.02
17 $499.98 $429.77 $381.68 $286.43
18 $515.80 $443.37 $393.76 $295.50
19 $531.61 $456.97 $405.83 $304.56
20 $548.00 $471.05 $418.34 $313.94
21 $564.96 $485.63 $431.29 $323.66
22 $564.96 $485.63 $431.29 $323.66
23 $564.96 $485.63 $431.29 $323.66
24 $564.96 $485.63 $431.29 $323.66
25 $567.21 $487.56 $433.00 $324.95
26 $578.50 $497.27 $441.63 $331.42
27 $592.06 $508.93 $451.98 $339.19
28 $614.10 $527.87 $468.80 $351.81
29 $632.17 $543.41 $482.60 $362.17
30 $641.21 $551.18 $489.50 $367.35
31 $654.77 $562.83 $499.85 $375.12
32 $668.33 $574.49 $510.20 $382.88
33 $676.81 $581.77 $516.67 $387.74
34 $685.84 $589.54 $523.57 $392.92
35 $690.36 $593.43 $527.02 $395.51
36 $694.88 $597.31 $530.47 $398.09
37 $699.40 $601.20 $533.92 $400.68
38 $703.92 $605.08 $537.37 $403.27
39 $712.96 $612.85 $544.27 $408.45
40 $722.00 $620.62 $551.18 $413.63
41 $735.56 $632.28 $561.53 $421.40
42 $748.55 $643.45 $571.45 $428.84
43 $766.63 $658.99 $585.25 $439.20
44 $789.23 $678.41 $602.50 $452.15
45 $815.78 $701.23 $622.77 $467.36
46 $847.42 $728.43 $646.92 $485.48
47 $883.01 $759.02 $674.09 $505.87
48 $923.69 $793.99 $705.14 $529.17
49 $963.80 $828.47 $735.76 $552.15
50 $1,008.99 $867.32 $770.26 $578.05
51 $1,053.62 $905.68 $804.34 $603.62
52 $1,102.77 $947.93 $841.86 $631.77
53 $1,152.49 $990.66 $879.81 $660.25
54 $1,206.16 $1,036.80 $920.78 $691.00
55 $1,259.83 $1,082.93 $961.75 $721.75
56 $1,318.02 $1,132.95 $1,006.17 $755.09
57 $1,376.77 $1,183.45 $1,051.03 $788.75
58 $1,439.48 $1,237.36 $1,098.90 $824.67
59 $1,470.55 $1,264.07 $1,122.62 $842.47
60 $1,533.26 $1,317.97 $1,170.49 $878.40
61 $1,587.50 $1,364.59 $1,211.90 $909.47
62 $1,623.09 $1,395.18 $1,239.07 $929.86
63 $1,667.72 $1,433.55 $1,273.14 $955.43
64-99 $1,694.83 $1,456.85 $1,293.83 $970.95
Page 14
Rate Guide 2021 Individual and Family PlansSutter Health Plus Rate GuideIFP RatesFor YourselfFor a Family
Licensed Service AreaAlameda CountyContra Costa CountyEl Dorado County (partial)Placer County (partial)Sacramento CountySan Francisco CountySan Joaquin CountySan Mateo CountySanta Clara County (partial)Santa Cruz CountyStanislaus CountySolano CountySonoma County (partial)Sutter County (partial)Yolo County
Rating Region 1 Sutter County (partial)Rating Region 2 Solano and Sonoma (partial) CountiesRating Region 3 El Dorado (partial), Placer (partial), Sacramento and Yolo CountiesRating Region 4 San Francisco CountyRating Region 5 Contra Costa CountyRating Region 6 Alameda CountyRating Region 7 Santa Clara County (partial)Rating Region 8 San Mateo CountyRating Region 9 Santa Cruz CountyRating Region 10 San Joaquin and Stanislaus Counties